Wednesday, December 31, 2008

Through the Prison Gates


Talking to some of my patients you'd think we're running a penitentiary at Wilford Hall. If I had a dollar for every patient begging me to let them go or who asked that I call the cops, FBI, OSA, CIA, etc I'd have, like, seven bucks. This is not because of particularly poor patient care -- I am inclined to believe we treat our patient's better on average than most hospitals -- but because our patients are out of their minds crazy. Delirious more specifically, but crazy nevertheless. Sometimes they try to bribe me, sometime they try to convince me through semi-coherent cookoo logic, and sometimes they just ask very nicely, but the universal statement always seems to be, "I shouldn't be here! Ahhhh!"

And how do I respond to these requests?

"Sir, would you like a BOOST?"

Actually we're instructed to talk them down which I am not sure has ever actually been scientifically shown to work, but it's what we do nonetheless. "Sir, why do you think the nurses are trying to kill you? They're sticking tubes in your penis, needles in your arm, and waking you up every few hours because they want to help you!" The restraints are good for you, ma'am.

In other news, this last week I won the lab lotto. Laboratory tests are ordered to confirm probable diagnoses and rule out improbable ones. Checking them every day is always a little like a scratch off ticket to see if we have just another case of pneumonia and diabetes or something much more exotic and rare, and a couple of days ago I won big. An insulinoma! Or at least I thought I did. The patient was hypoglycemic and with super high serum insulin and c-peptide levels but it turned out it was just a gnarly side effect of her floroquinolone antibiotic. Still pretty unusual and still quite a prize. I was excited. Now I am told I get to write up an ACP poster for it, whatever that means.

And here's our Christmas tree!


Happy New Year!

Friday, December 19, 2008

Let's Get Intensive

Back on call again. Still sucks.

I've realized, though, that for those whose only impression of "call" comes from Gray's Anatomy and Scrubs, being on call is a hazy, ill-defined concept, and reality's blurred. My repeat assertions that "it sucks" have surprisingly done little to clarify the matter. The truth is, aside from the casual sexual encounters with coworkers, there is not much in common between the real world and the world of make believe. As an example, an average call in the Medical Intensive Care Unit (MICU):

  • 0530, Wake up, realize it's a call day, grimace.
  • 0600 - 0630, Drive to the hospital in silence. This is likely the happiest I'll be all day today.
  • 0630 - 0635, Arrive at the hospital and change into scrubs that I have found and scavenged throughout the hospital on previous non call days. Sometimes they fit, sometimes they're stained, sometimes there're huge unexplainable holes in 'em.
  • 0635 - 0830, Begin pre-rounding on my old patients. Pre-rounding consists of recording a slew of vital signs, lab values, consult information, nursing reports, radiographic data, drip rates, machine settings, and then, finally, talking to the patient for 5 minutes. Thankfully many ICU patients are on ventilators and do not have much to say.
  • 0830 - 1200, Round with staff and fellows. Staff rounding consists of telling the staff physicians about everything I have just collected and then politely nodding while my co-interns do the same.
  • 1200 - 1215, Run the board with the resident. Basically we find a big marker board and cover it with little check boxes of the things we have to do today.
  • 1215 - 1230, Get lunch at the cafeteria to go. As the food choices are often some sort of fish, often pollock -- whatever the hell that is, and some odd mix of sides that do not go together I frequently find myself eating a lot of grilled cheese sandwiches. It turns out BAMC has the best grilled cheese sandwiches.
  • 1230 - 1600, Work. Write notes, write orders, record more information, and repeat. Sometimes I accidently find myself talking to my patients which only puts off all the work I have to do.
  • 1600 - 1700, Take sign outs. Around this time, while I am still going about my regular business, various other interns page me to come check out their patients for the night's cross cover. This is when I get to add more little boxes to all the previous boxes I had already checked off for the day.
  • 1700 - 1730, T-cons and emails. If there's a lull in the work and we have not already had to admit any new patients, I just may get to take care of the other, non-ICU, work that builds up 24/7 year round. T-cons are things I need to call my outpatients back about and emails are typically incomprehensible military things I need to delete or poorly characterized tasks I have to take care of somehow, somewhere.
  • 1730 - 1745, More sign outs.
  • 1745 - 1130, Admit patients. Nightly we receive anywhere from 0 - 5 new patients from the ED. Typically it's around 1 - 3. Each individual patient seems to take me about 2 hours to fully work up, admit, and write a History and Physical (H&P) on. I would say I am slow but I honestly do not know how to go about it much faster without cutting corners. Or at least more corners than I am already comfortable cutting.
  • 1745 - 2330, Cross cover. At the same time I'm admitting patients I also gotta take care of all those pesky check boxes!
  • 2330 - 2350, Dinner. Hunger pains and hypoglycemia force me to momentarily stop or slow what I am doing to eat. Thankfully there're usually other things that can also simultaneously be done while eating. Like checking boxes for example.
  • 2350 - 0200, More admits and cross cover.
  • 0200 - 0205, Think about sleeping, but then do more admits and cross cover.
  • 0205 - 0245, Take care of a crazy patient. Inevitably someone will completely lose their mind over the course of an evening and I get to try and persuade them not to. It seems restraints and tranquilizers are not in fashion these days.*
  • 0245 - 0250, Think about sleep again, but then do more admits and cross cover. Maybe watch part of a show in an unconscious patient's room.
  • 0250 - 0345, Code Blue. Someone is dying and it's my job to stop it! Or at least delay it for another few days or weeks till it inevitably comes about.
  • 0345 - 0545, Admit again.
  • 0545 - 0700, Finish whatever needs finishing, and pre-round on my old patients if there's time. Sometimes I eat a yogurt cup.
  • 0700 - 0830, Check out with the CCU (Cardiac Care Unit) team. This is when I learn that despite working continuously for > 24 hours straight it just isn't good enough.
  • 0830 - 1100, Check out with the MICU team and staff. This is when I learn that because I worked continuously for > 24 hours straight it's clear I did my best. Good game everybody, good game.
  • 1100 - 1230, Finish whatever needs finishing again. Complete notes, complete H&Ps, and sometimes fall asleep at or on my keyboard.
  • 1230 - 1231, Leave the hospital. My reward? The sensation that someone has thrown sand into my eyeballs. Whether cloudy or sunny, wet or dry, walking to my car is always a mildly stinging experience.
  • 1231 - 1300, Drive home with music blaring and singing along. This is likely the happiest I'll be all day today.
  • 1300 - 1530, Eat, shower, and go to bed.

Total time awake: 33 hours

Friggin' miserable.

In international news, President Bush. Guy can dodge bullets. Or at the very least well thrown shoes from close range. And Prime Minister al-Maliki? Way to step in where the Secret Service was not. Batting away gun shots -- err shoes -- with greatest of ease. I know I don't have moves as smooth as that. Would have taken both shoes square on the nose, back to back. No country would take us seriously afterward. Really, though, it seems global politics is going more and more the way of Austin Powers these days.

"Who throws a shoe? Honestly! You fight like a woman!"

In domestic news, we've got Christmas lights!



Almost looks respectable from this angle!



This angle not so much. It turns out I did not quite measure the required length of lighting very well. But, uh, it's the thought that counts?

*Not to suggest that they should be. Restraints and tranquilizers should only be used when absolutely necessary. Like when the patient has made you angry.

Monday, December 8, 2008

Christmas Present Apraxia

Although I am still fully in possession of all my faculties and still have complete control, it would appear, over my senses and motor function, it seems I just cannot wrap a good Christmas present. Despite some 26 years of practice now -- yes I started wrapping gifts just 5 months after birth -- my wrapping skills have improved only marginally, producing most recently this monstrosity:



The fact that the corners are not crisp, there is an overabundance of tape, the flap lengths are all uneven, and that I did not even cut enough paper for the whole project and so had to graft on not one but two extra appendages of wrapping paper are only partially disguised by my not so clever use of bows, poor lighting, and unusual construction patterns. Indeed this is the one skill I have picked up over the years. How to wrap presents so clumsily that it appears as if on purpose. Such a secret is what keeps our nation's postmodern artists fed, and it works for me. Occasionally, though, namely when the gifts are large and square, I do succeed in finishing a presentable product:



Not bad, huh? But then I go and produce something like this:



The wrapping job's ok, but I definitely had to resort to sticky notes as improvised gift tags. And as I ran out of scotch tape I had to resort to staples. Sarah's gift is now securely fastened to her shipping material. Actually I lie about the tape -- it's the one thing I do make sure I have an abundance of. And bows!:


Beautiful! I really don't know how I have failed to get better at this -- perhaps I simply just don't practice enough -- we need Christmas at least three times a year! -- but I have. Although it should simply be a matter of roughly measuring size, slowly cutting smooth lines, appropriately folding corners neatly, and taping conservatively in key areas, I cannot quite pick it up. I even managed to cut myself at one point with the x-acto knife -- someone will get a little extra love and blood with their present this year -- and I am still not entirely sure when or how. Whatever the case, Christmas wrapping makes me merry and my general lack of skills aside I am happy for the time being.

Next up: Christmas trees and Christmas lights. Let's pretend I don't have the ICU coming up in three days!

Thursday, December 4, 2008

Busy Like a Hamster

I have been busy!

And not at the hospital. So much. Which is why I used an exclamation mark. (Not just for teenage girls and text messages any more.) I have been so busy I barely even have time to write this garbage -- err blog. Amazing dedication!

So what have I been doing? Well, things! I got my car wash, bought some Christmas presents, visited family in California for Thanksgiving, went to a wedding, saw some college friends in Houston, test drove a MINI Cooper Convertible and Jeep Patriot, returned some presents, paid off my student loans, had clinic, wrapped Christmas presents, decorated a Christmas tree, visited some other family in California, mailed some presents, went to the optometrist, decorated another Christmas tree, got new glasses, got my teeth cleaned, read a book, saw Bolt, Quantum of Solace, and Role Models, cleaned my shower, bought some picture frames, did some research on colistin resistance in Acinetobacter, got a haircut, got an oil change, framed some pictures, went to the mall, bought some groceries, got a filling at the dentist, and saw Boyz II Men (for free mind you) at a USO show. All that and not a single amusing story. Well, I guess the way my 3 year old nephew flexes his shoulders forward when he stutters out his words like some sort preschool bouncer is pretty amusing, but you really have to be there.

In other news, this! Seems despite the oft stated claim by all those liberal, tree-hugging, monkey-headed socialists out there that punishment is not an effective deterrent, one psychology study suggests that it can serve as a corrective force. But the real lesson here: the social sciences are and will always be science-light. In other words: my political science degree is a bunch of high-sounding nonsense. Perhaps this article should be read with this!? Just perhaps.

On a final note. I bought a giant bag of Nerds candy for Halloween and nary a kid showed up to receive it. Despite my best efforts to eat far more Nerds than is reasonable on my own I still have about 70% of a giant bag of Nerds on my hands. I am taking suggestions.

While some people find it helpful to fast before Thanksgiving dinner, we know it's best you prime the pump before hand. Preferably with Cheetos, Lunchables, and as much soda pop as you have cup holders for.

Wednesday, November 19, 2008

Cats and Birds and Brains and Things

It's Multi-Discipline Time!

A little bit of everything means a whole lot of nothing. This next month I will practice a little bit of psychology, a little bit of ophthalmology, a little bit of ear, nose, and throat, and I would, were I not taking leave, also practice a little bit of orthopedics but ah shucks I just won't have the time. Practically speaking, however, no one really wants to orient and integrate someone into a team who will only be with you for a week so I will spend most the next 28 days ignored while fondly staring off into the distance.

Even better, though, no pages!

And what's better than that?

No call!

And what could possibly be better than no call you ask?

Two day weekends!

Fantastic. Morale is much improved.

So the Snow Birds are finally making their way south. "Snow Birds," for those of you not fortunate enough to live south enough in this fine country of ours to be familiar with the term, are elderly folk who migrate with the seasons. Generally they only stop through San Antonio along their way further down into the Valley, but some do stay awhile. What that means for us at the hospital, practically speaking, is an influx in patients who have half their medical records inaccessible in the great barren, frozen North. Not terribly convenient. Medical care aside the Snow Birds are remarkable for their migratory habits and ability to always return home regardless what obstacles may come their way. Some say they follow the stars, some say the have an innate ability to tract the global electromagnetic field, others say it has something to do with all the hardware in their knees and hips , but whatever the reason it's pretty impressive. Sometimes we affix clinic notes to their legs with TED hose when the server's down. It's almost as efficient as electronic medical records.

And lastly a cat update. Despite repeated application of moth balls the cat problem has not changed significantly. An opossum has joined their ranks oddly enough -- I would have figured cats eat opossums or vice versa -- but by and large they still generally do as they please. What is new is that the they seem to have taken to the trees. Whether for nesting or roosting or the simple fact that there is simply not enough space for them any longer on the ground, every tree on the street seems to have a cat or two in it. Whenever I come home from work one will inevitably jump down and scurry away for whatever crazy cat reason they have in mind. I would like to shake the trees and see what comes out, but the last thing I need is a cat on my head so for now I will tolerate them. Soon they will move into the attic and under the furniture. At that point hopefully my apartment will be done; I don't expect Laura to make it through the year.

Catz!

Thursday, November 13, 2008

My Greatest Weakness is I Care Too Much

Or rather am forced to care -- personally I don't give a damn.

It is perhaps ironic, or perhaps not, that the process of training physicians arouses in its would-be doctors feelings that are often so exactly the opposite of what it is clinicians are supposed to feel. Case in point: coumadin. Perhaps it'll make you bleed out your bottom, perhaps it'll make you bleed into your noggin, perhaps, just perhaps, it'll save your life. Of course that's on a running average over a sufficient time period. For most people it'll just seriously inconvenience their lives and lead to unsightly bruising. But oh the joys of administering it, and ho what greater joys are to be had if the patient cannot competently do so themselves. This last block what did I get to do? Give coumadin! What does that mean?! Well let me tell you.

It means I had to convince the patient that first she needed to start taking Lovenox shots because, you see, coumadin takes a few days to find itself. It's a slow acting drug. Then, once she had conceded, I had to write a prescription for the Lovenox, find out the fax number of the home health company that would take care of her, fax the prescription to them, ensure they'd receive the fax, fax it again when they didn't, ensure receipt a second time, order additional every other day blood testing to ensure medication levels were sufficient, arrange for someone to follow up these levels while I was out of the hospital for the weekend, and then report all of this information to my master and commander for their seal of approval. Then we get to the coumadin. We start with a dose that sounds about right, repeat the prescription writing process above, explain to the patient to take all the dose and not just part of it and that no her belly pain is not due to the coumadin, ensure she has extra different sized pills in case we have to change the dose, and again ensure there is someone willing to follow up the numbers while I am gone. In the days long gone I am told docs had to follow the blood levels themselves indefinitely. Today, however, we have a coumadin clinic. The clinic it turns out, however, has phones that do not work (how terribly convenient?), only has classes on Tuesdays and Fridays, works ridiculously little hours, has an intricate consulting process requiring secret passwords and ancient languages, is closed completely on Thursdays, and seems to be generally run as clandestinely as possible. I almost wish for the good ol' days. The end result of my labors? A woman can live a little longer. Or die a little earlier it's hard to say with statistics. All for 45 minutes of my time and a tiny bit of my soul.

But there are good stories too! Like my colitis patient who kept an intricate record of his diarrhea for me every day in the hospital so that my work was a little easier in the morning. And the illuminated, plastic landscapes hanging in the Intermediate Medical Care Units (IMCU) that make it feel a little less like a dungeon while also suceeding in keeping the patients awake at night. And the dirty old man in clinic who told me naughty jokes while his half-demented wife whom he lovingly cared for cackled on about who knows what in the background.

Internship sucks right now. I hate it. The reasons are varied, some good, some bad, some legitimate, some not so much, but overall it's a demoralizing drain. There are some good times to be had -- though looking over my list the term seems to have become quite relative -- but mostly the best of times are had as far away from the hospital gates as possible. Only one and a half years left before some semblance of a good life returns. Only one and a half years left.

We did go to Six Flags for Fright Fest, though. Lots of fake blood and plastic skulls to be found. Spun around a lot and then had a funnel cake.

And I did finally venture up top the Tower of Americas to the Charter House bar. It was nice. The view was lovely. We went home.

I am feeling ambiguous and muddled. Perhaps it the lack of an appropriate sleep wake cycle.

Excelsior!

Wednesday, November 5, 2008

The End of the Beginning

I have often wondered if I would salute the current Commander in Chief. Misgivings aside I likely would. Shortly, however, I will feel no such compunctions.

I voted for Barack Obama a little over a week ago. I would have enjoyed being part of the excitement of a November 4th election as I have in years past, but my work schedule simply would not make it practical. The sentiment I felt tonight was not mostly one of excitement that my candidate won, however, -- though I am excited -- but rather one of reverential sadness that my other candidate lost. As I have said before I would have liked to vote for both men. McCain is, I believe, one of the United States' truly great men currently. He would be a president whom I would proudly serve and a leader we would be undeserving of. In 2000 and 2004 there would have been no question. But this year, unfortunately, he tried to have it both ways. He wanted to be both independent Maverick and reliable Conservative at the same time. Whether he was always this and I had simply lived for years in blissful ignorance or this was a miscalculated political blunder I do not know, but whatever the reason I could not vote for him when the alternative was Obama. And so now I'm a little sad. McCain is a good man who turned to bad policy. I wish I could have voted for him.

The election done and over with we are still faced with a staggering economy, two undecided wars, an immigration policy in need of reform, a host of rogue nuclear states, an infrastructure in need of repair, a resurgent Al Qaeda, a mediocre education system, an addiction to foreign oil, a bloated and inefficient health care system, an international name in disrepute, and a "planet in peril." Good luck Barry, McCain may have dodged a bullet with this one.

Friday, October 24, 2008

A Labor of Love

I have been working 80 hour weeks for the past five weeks. I have three left to go. I do not enjoy it much. I leave to work with it dark outside and return to work with it dark outside. In these harsh and trying times I like to think of a block back at BAMC when my co-intern stepped in to visit a patient of his.

The woman, elderly, foreign born, and a bit demented, had just had a nasogastric tube inserted through her nose to relieve the pressure building up in her gastrointestinal track. Being so demented she did not terribly appreciate this.

Upon entering the room to see how the procedure had faired she, from her curled up position in bed, waved her grizzled hand and said in her thick East European accent, "Traitor."

"You'll pay for this."

The joys of patient care.

Today a family in clinic gave me a pack of gum. It was pretty good.

Ahh... for the good ol' days....

Friday, October 10, 2008

The Gold Standard

"The gold standard." A descriptive phrase in medicine -- and I'd imagine probably in other disciplines as well -- used to such excess that a little scowl briefly crosses my face whenever anyone says it. With the high value placed on communication in health care and the tendency to imitate I needless to say spend quite a bit of my day scowling. What it refers to, if it is not already clear, is the test, study, drug, whatever, considered the best and most effective in accomplishing whatever task it is you have in mind. For finding vascular blockages it's usually angiography or venography. For identifying offending pathogens it's usually bacterial or fungal culture. For treating penicillin sensitive Staph aureus infection in a non pen allergic patient it's penicillin. When it comes to medical students, I have learned recently, it's Dan Marino. No, not Dan Marino the former Miami Dolphins quarterback -- I am fairly certain he either passed away shortly after filming Ace Ventura or he was immediately cast in bronze and shipped to the football hall of fame shortly after retirement -- but the Dan Marino from Jersey. Or maybe it was New York. I am not entirely sure where Dan Marino the fourth year medical student was who worked with us for two weeks in the Cardiac Care Unit (CCU), but he certainly set the industry standard. Why? Partly because he was always so pleasant, helpful, and interested in his work. Partly because I am pretty sure he was always smiling. But mostly simply because I liked introducing to people my medical student: Dan Marino. Good kid that Dan Marino.

This last week I have learned that although San Antonio has the gold standard in small Spanish missions used in acts of rebellion from foreign powers, it does not in zoos. Nevertheless as San Antonio generally sets the bar pretty low for most things, the Spurs aside, I was mostly impressed. The zoo here it turns out is pretty nice. I was expecting a glorified petting zoo with a taco bar, but actually got something close to a world class zoo, research center, and wildlife repopulation program akin to the San Diego Zoo in California. Except for the fact that, their extensive bird collection aside, they only seemed to have one of every animal. Even when the descriptive plaques would state, "always found in herds of ten or more, the social such and such" would almost always be found alone. Maybe with a single ostrich or antelope to keep him company. So even though the giraffes and zebras had impressively large exhibits. There was just one. One zebra. Hanging out. Probably bored out of his mind. I don't know if animals can go crazy, but they just may here. The scarcity of certain animals animals aside, however, it was a fairly nice place that I would recommend everyone go to. Everyone. Even yo mamma.

Anyway, the gold standard of Pembroke Welsh Corgis ladies and gentleman:
(Her name is Ahi. Or Cupcake. Or Bailey. It depends on who you ask.)


Thursday, September 25, 2008

The OSBID Service

I always expected sadness in medicine to come in the form of unexpected morbidity and mortality. Someone under my direct, active care expiring despite the best efforts of the team I am a part of. I have thankfully not experienced it so far this year, but have certainly in the past and so I can say, too, from experience that it is heartbreaking.

But only momentarily. It is the shock more than the event which brings about the feelings. Sad things happen all the time in medicine, it is often only when they catch you off guard that you feel them, however. Like a bullet to a flack jacketed frame, I am stunned briefly, but otherwise unhurt. For a short while I am without breath, but I recover and aside from some mild bruising am no worse for the wear.

I also always appreciated, I feel, the subtle, grinding effects of disease on clinicians. Sick, sad, hurting, angry, and confused patients and families get underneath the armor to slowly wear you down. It is not the only side of medicine -- there is an equal share of pleasant patient interactions to reward and rejuvenate -- but it is a significant side nonetheless.

What I did not expect, and what I did not prepare for in all this, was gratitude. Not thankfulness for refilling someone's prescriptions or a vigorous hand shake for treating grandpa's chancroid or a even kind word from someone who's pain was heavily medicated, but gratitude undeserved and a smile in spite of pain.

Working on the Infectious Disease (ID) service at Brooks Army Medical Center (BAMC), now more commonly unofficially known as the Orthopedic Surgery and Burn Infectious Disease service because of all the war wounded, I experienced such kindness in spite of loss on a somewhat regular basis. Most of our patients were amputees with infected stumps or burn victims with infected everything. Victims of IED blasts, RPGs, and mortar attacks. Many times, unfortunately, despite our best efforts and the collective intelligence of what I believe to be some of the smartest infectious disease doctors in the nation, things didn't get better. Antibiotics these days can only do so much. But even the completely recovered were still, well, amputees and burn victims. Young men and women whose lives would be forever different for the worse. It is possible to still live a happy and fulfilling life injured as they were, but chances are certainly not in their favor. Everyone knows this, I know this, they know it, and when they then thank me for doing a little to make life suck a little less, well, I don't know what to do.

This was worst when I could see through their ruse. Frequently I would see my patients in the cafeteria -- no frowns were on their faces but their shoulders were often enough sagging from emotional fatigue -- and we would bump into each other. Recognizing that, hey, it's me, your physician!, they would briefly, magically transform themselves and on their face would be a generous smile and a pleasant hello. Perhaps we'd exchange a few pleasantries even. If we didn't run into each other, however, if they remained anonymous, their grief and distant eyes remained. I'd see them tired enter and tired leave. It is not that I think they were being insincere or just polite -- truly their motivations are unimportant here -- but rather, simply, I was able to see them with their shields down as well. I saw the disease taking its toll. Being strong means you take the pain not that it isn't there, but it is often easy to interpret things the other way for those not enduring it.

So it is this combination: seeing them freely hurting and seeing them graciously smiling that gets me. It is one of the few experiences during the day that get me out of the hustle of paper work and data collection and actually make me stop to feel what I am doing. It is not that I do not care for or about my patients otherwise -- I certainly do -- it is just that the intellectual practice of medicine often detaches you in the process. I am on the Cardiac Care Unit (CCU) service now and people are dying but it is not the same. I will briefly shed a few tears for some of the lost in the unit, but I have so far only been deeply moved by the the patients I've taken care of while on ID. Unexpected.

So that was sad. Anyone watch Wipeout?! What a great and entirely terrible show.

Wednesday, September 17, 2008

War and Peace

And now for the longest post ever.

A while back and on a variety of occasions I have discussed or heard discussed amongst family and friends the War on Terror and the problem of Islam. I have since come to the conclusion that most people don't know what the hell they're talking about. Being the enlightened and noble individual that I am I took it upon myself to construct a quick primer of the state of Islam and politics in the Islamic world for everyone's edification. This was all before I started residency, however, and as time ran short and I grew increasingly long winded the project got a bit out of control. Instead of being a few pages it grew into 9 or 10. So now, for those with the endurance, the fruits of my effort. Feel free to read, snooze, scoff, and let me know how I, too, don't know what the hell I'm talking about.


We’ve been fighting this War on Terror now for the better part of a decade. We’ve devoted billions of dollars, thousands of lives, countless hours, and unknown opportunity costs to combat what is essentially, for the most part, a war against militant Islam. Unfortunately, despite these investments few people have more than an introductory understanding of who this enemy is, and, equally unfortunately, for a great number of people this understanding is not a basic but budding knowledge of the threat, but rather a skewed caricature of an entire world of people. For what it’s worth then I’ve decided to momentarily pause my normally scheduled monotonous stories about things people don’t much care about to offer instead a hopefully broader and more complete view of the Muslim religion as seen in its people. At least to the extent that I can. I write this not because of any great affection for Islam – I care for the average Egyptians and Syrians as much as I care for any other foreign stranger which is admittedly not much – but because if we are to win a war so poorly defined we had better at least be able to clearly define our enemy.

Islam in the Middle East – Hamas, Hezbollah, the Palestinian Liberation Organization (PLO), Iran, for the most part they’re all the same. Arabic synonyms for crazy. To hell with them all, literally. While to an extent such sentiments may be understandable, to not go beyond them is to do a disservice to those who we send abroad to wage our wars for us. Although we are not currently at war with any of the Middle Eastern factions, save our conflict in Iraq, we support a wide variety of actors who do and, depending on how things go, that fact may only be temporarily true. So are all the parties the same? No, of course not. Few would truly make such a claim, but few would also be able to explain why. The reality is these groups vary in many significant ways, and more in just the way they wish to send Israel back into the sea. This is seen most readily by the fact that it was only a few decades ago that, at varying times, both Syria and Jordan have gone to war with the PLO and its militias, and most recently the Palestinians have been at war with themselves. So to start let’s begin with the governmental players.

Syria: Nominally a republic, the country has been ruled essentially as an autocratic state complete with a powerful secret police for some time. It is, however, a secular republic, and as such has at times felt no compunction with aiding Christian militias in Lebanon or bashing Muslim heads in its own country. Truly, though, like most states in the Middle East the ruling family uses religion as an occasional tool for political manipulation more than anything else. It has been charged with and likely continues to support various terrorist groups throughout the region including Hezbollah and a wide number of Palestinian liberation bodies. Although Syria has accepted numerous refugees from Iraq, it is no great friend of the current government and its poorly policed border is allegedly a significant gateway for foreign combatants to enter the country. Early on in the second Iraq war claims were made that Iraqi WMDs and high ranking political figures were hiding in Syria, but this has never been substantiated and many fugitives allegedly in Syria were subsequently caught inside Iraq.

Lebanon: Currently a nation in relative turmoil as the Western leaning, democratically elected government continues to battle the rising power of Hezbollah. It was for many years dominated by its neighbor Syria as a result of its intervention in the destructive Lebanese civil war during the ‘70s and ‘80s, but they were kicked out only a few years ago after the allegedly Syrian supported assassination of a former Lebanese primer minister. The current muddle is further complicated by the demographics of the nation as it has substantial Christian and minority Islamic populations as well as a significant portion of its population with a fairly secular, Westernized world view. Due to this continuing confusion and as a result of the long years of war and occupation by Syria, the Lebanese military is not very well developed, and, despite a UN force in the region, the south of Lebanon is effectively controlled by Hezbollah.

Egypt: One more nation on the extensive list of Arabic republics who’s actual governance tends to stray from republicanism. Political parties are technically allowed and elections technically take place, but President Mubarak is into his fifth term and most votes are far from free and fair. Also like other Arabic semi-autocrats, Mubarak makes an issue of Islam often only when it is politically expedient, and his continued poor rule fuels resentment which is frequently channeled into fundamentalist Islamic bodies that provide social services that the state otherwise fails to offer. One such group is the Muslim Brotherhood which has won ever larger portions of the legislature in recent elections -- though it is still a minority -- despite its repression by the government. In the grand scheme of things Egypt has played a relatively moderate hand with Israel and was the first Arabic state to recognize Israel’s right to exist.

Palestine: Currently under divided rule with Fatah, the long standing lead party of the Palestinian Authority (PA), in control of the West Bank, and Hamas, the most recent electoral victors, in control of the Gaza strip. Because of Hamas’s long history of violence towards Israel and its continued stance that Israel has not even the right to exist, its mini-state is in under nearly complete blockade by the Israelis and the Israeli government has continued to refuse to transfer taxes collected on the PA’s behalf. Despite the focus on the religious nature of many of the actors in the Israeli-Palestinian conflict, many players have had significant competing nationalist ideologies in addition to their spiritual belief with their patriotism frequently taking dominance over their religious zeal. The Al-Aqsa’s Martyr Brigades is one such example, and next to Hamas and Hezbollah this Fatah associated militant group is a major competing terrorist organization. Due to the long standing nature of the conflict and the continued dominance of the Israeli government in many Palestinian controlled areas a sizeable portion of the Palestinian population does not even live in Palestine but instead inside a number of refugee camps in neighboring states. Fatah, though historically a fairly corrupt organization, has moderated significantly under the current leadership of Mahmoud Abbas, also known an Abu Mazen, and is currently receives significant Western and Israeli support.

Israel: Although not frequently advertised, Israel has a significant Arab and therefore Muslim population of its own. For the most part living in peace as citizens of the Israeli state, their support of its actions and policies is weak. Most importantly, though the Jewish community continues to grow in Israel, it is not doing so as fast as the Israeli Arab community.

Saudi Arabia: Unlike much of the Arab world, Saudi Arabia makes no pretenses about the autocratic nature of its rule, and also unlike a good portion of the Arabic world Saudi Arabia’s Muslim population is fairly homogenous embracing a particularly belligerent form of Sunni Islam known as Wahhabism. Although these facts can be exaggerated at times, the fact of the matter remains that in the end when all things are considered Saudi Arabia is a net exporter of terrorism both in terms of financial resources and foreign fighters. There are hints of liberalization here and there and elections have taken place at very minor levels, but the house of Saud is likely to remain in power and through the same means for a very long time.

The Mini-States: The Middle East also has a collection of other statelets situated all along the periphery of the Arabian Peninsula. These include Kuwait, Bahrain, Qatar, Yemen, UAE, and Oman. While grouping them altogether does them something of a disservice as they are rather diverse, they are important not for these reasons but because of their wealth (with maybe Yemen being the poor exception.) This wealth gives them an influence far disproportionate to their size or population, and like with so many rapidly growing, autocratic states, growth has become the new ideology. Nationalism and religious fundamentalism have their adherents for sure, and the vast majority of the Muslim population in these countries are undoubtedly pious by most standards, but the essential fact remains that, for many of the Gulf states economics is the first priority. In this sense, some Muslims worship a wide variety of gods.

Hezbollah: The Party of God. A little bit Palestinian guerrilla movement, a little bit Iranian terrorist puppet, a little bit Lebanese political party, and a little bit religious charity organization. Hezbollah is a multi-faceted, multi-faced organization whose variety of talents has allowed it to adapt and expand remarkably well in the oft changing world of Middle Eastern politics. Although for a long time it was only one of many players in the region, it has risen to an esteemed position after Israel’s ill fated war against it in Lebanon only a short while ago. Having survived the power of the Israeli war machine while the whole time lobbing crudely made rockets into Israel-proper, Hezbollah has made itself into something more than simply another terrorist organization. Violence aside, the group has been active in Lebanese politics and has provided critical social services for many years. All that aside, the paramilitary group is unique also in its tactics. For one, although it has used suicide bombings in the past, such attacks are not a staple in its arsenal. Its use of rockets, though poorly guided, kidnappings and attacks on Israeli military positions on the other hand strongly support its claim that it is not a terrorist body but instead a paramilitary organization that should be respected as a resistance force. Moreover, though Hezbollah professes an ideology crafted at least in part by the Iranian ayatollahs, its aims are generally much less radical and more limited than what is practiced in Iran. For all these reasons, and its success in its use of violence, Hezbollah had widespread support in the Middle East and is, in many ways, almost a state unto itself.

Islam in Iran – The rest of the Middle East is nice, but Iran is where the money is. Syria and Palestine, for all their efforts, have never made it into the Axis of Evil. They will always be second tier to the nuclear ambitions and extensive terror network of the Iranians. The place even has a nefarious sounding spiritual leader, the Ayatollah. If that doesn’t sound sci-fi bad guy enough, well, perhaps Ahmajinedad would do it for you? That’s at least incomprehensibly foreign.

The truth is Iran has been and is doing a whole mess of bad stuff, and there is legitimate reason to combat and, to an extent, fear its activities. The truth is also, on the other hand, that Iran is a great deal more than the sum of its villains, and it’s important to appreciate this fact. While the country is a supporter of terrorist organizations in Israel, Palestine, Lebanon, Iraq, and elsewhere -- and indeed part of its very own Revolutionary Guard, the Qods, is technically classified now as a terrorist organization itself -- Iran has also supported our war against the Taliban in Afghanistan and currently supports the war on drugs as executed in Afghanistan. Although many of its people, predominately Shiite in a Sunni dominated religion, are quite willing to support their faith through violence, many of its people are similarly led by irredentist yearnings for a return of the glorious Persian empire. Additionally, in many of its larger cities such as Tehran, the capital, there are significant bodies of fairly well educated, modern, and secular leaning Iranian citizens as well. In the mid 1990’s with the change in rule from Ayatollah Khomeini to Ayatollah Khamenei there was even brief hope for the democratic liberalization of the state under the reforms of then President Mohammad Khatami. This obviously was not successful, but nevertheless it had the support of a significant percentage of the population and indicated to both the leadership in Iran and the rest of the world that the Iranian people are not a homogeneous, theocratic mass.

Iran offers an excellent and under appreciated example of the compartmentalization of religious thought. Islamic fundamentalism requires a willful suspension of disbelief, but it would be foolish to then assume that this same unreasoning behavior is applied to all aspects of a zealot’s life. By and large it is not, and instead such faith is but one irrational belief held by an otherwise rational actor. Now as with so many things craziness often begets craziness, but treating all adherents of such faiths as being beyond the bounds of reason is unfounded. Iran’s foreign policy is powered as much by nationalism and realist politics as it is a hunger for the expansion of revolutionary Islam. The same country that champions a violent, anti-intellectual brand of religion is also the state with the fastest growing rate of publications in scientific journals in the world. The same country that seeks to export Islamic theocracy only a short while ago supported Orthodox Christian Armenia over Shia Islamic Azerbaijan in their conflict together. And the same country that seems to be now resolutely set on developing atomic weapons and flexing its muscle in the region was only a short time ago, under the leadership of organizations in the United States and the reformist government of Khatami, open to negotiating a resolution to not only the nuclear issue but the wider issues of terrorism and regional stability as well. Because of all this although negotiations may in the end turn out to be fruitless and a compromised peace may be impossible, to assume this from the get go would be to do a disservice to those who would directly fight the ensuing war and all the generations that would have to deal with its repercussions. The Iranians are zealous, but they are not crazy. In the end we may have no choice but to resort to violent conflict, but to jump forward to such a conclusion without expending every reasonable resource otherwise would be both unthinkably ignorant and unforgivingly foolish.

Islam in Africa – After establishing a solid foothold in the Middle East Islam quickly spread both east and southwest. In the latter it quickly replaced various Christian and pagan sects deeply entrenching itself in the states of North Africa helping to create a region that is distinctly different from the rest of Africa at large. It is here where Al Qaeda based itself for a number of years, it is here where some of the worst, most abhorrent violence has been committed in the name of religion in the modern era, and it is here where militant Islam is, in some states at least, expanding its domain.

Algeria: In the grand scheme of things and in the small scheme of things Algeria is insignificant. Like many other African states it has never had much in the way of a stable, impartial government nor has it has it ever had much in the way of a sizable economy outside of its modest oil reserves. What is has had, however, and may be experiencing a renaissance in is Islamic extremism. Shortly after independence from France, fundamentalist Muslims in the country began clamoring for power along with their fellow nationalist, socialist, and autocratic compatriots. Although they initially had little success in time they gained prominence through the development of the Islamic Salvation Front (FIS), an organized political party, and later through the Islamic Salvation Army and Armed Islamic Group (AIG). It is with this rise that Algeria can serve as an interesting historical teaching point as had full democratization taken place as was scheduled in the early 1990s the Islamic Salvation Front would have come into power having won a significant majority of the first round elections. As many of its leaders openly advocated a return to sharia based system of rule the military intervened before the second round of elections could take place thus sparking the civil war which would crush the FIS and AIG only after the beheading of thousands of Algerian security personnel and civilians at the hands of the latter. During this time the military committed its own share of war crimes and so, despite its eventual victory, violence still occasionally flares and anger still occasionally lingers. A small splinter faction of AIG has reorganized under the Al Qaeda Organization in the Islamic Maghreb.

Sudan: Long before the Sudanese government was smashing the heads of various African groups in the Western Sudan (Darfur) it was smashing the heads of various African groups in the Southern Sudan. And long before it became a dictatorial state focused primarily on survival, it was a dictatorial state focused on the expansion of fundamentalist Islam. Today the government continues to exist only through the wiles of its rulers and the strength of its limited oil exports, but its public patronage continues to remain primarily Arabic Muslims around Khartoum and the northern half of the country. It is this group of peoples who have traditionally held power in the Sudan, and who continue to support the state’s repressive behavior against minority populations elsewhere in the country. Although its pan-Islamic torch bearing credentials do include briefly housing Osama bin Laden and allowing for the development of Al-Qaeda training camps, to cast the Muslim population of Sudan in this light would not be entirely appropriate. Islam in Sudan serves primarily to darken already drawn racial and ethnic dividing lines. The country is at odds with itself, and violently so, between the aforementioned Arabic Muslims in the north and the Christian and Animist Africans in the south and west. As the nation is increasingly torn apart and resources become ever fewer, these populations have had to compete more and more fueling the cycling violence. With this in mind, Islam has become less a call for jihad and more simply one more ethnic characteristic to distinguish the haves from the have-nots.

Somalia: Like the rest of North Africa, most Somalis have always been Sunni Muslim -- in fact Somalia is one of the most homogeneous predominately Muslim nations in the world currently. It has only within the last decade, however, that the faith has begun to be militarized. Like in Chechnya, Islam existed in the Horn of Africa for centuries as a religious practice primarily and a political movement rarely if ever. Power was centered mainly along family and clan lines, and allegiance was not to religion but to these. This state of affairs continued mostly unchanged till collapse of the state in the early 1990s with the political vacuum that resulted thereafter. With the country torn apart by warlords, the UN supported transitional government impotent to affect change, and no hope for greater than a decade many Somalis began to look for a new savior in radical Islam. They found this in the Islamic Courts Union (ICU), which promised security through a harsh justice based on sharia. With religious judges leading the movement Somalia was on its way to a kritocracy before Ethiopia intervened on the transitional government’s behalf. The end result is more conflict, more disorder, and a population increasingly divided and desperate for order. Like in so many states fundamentalist Islam has risen not necessarily because of its perceived superiority to all other forms of government, but rather because it is superior to chaos and uncertainty.

Islam in South Asia – The story of Islam in South Asia is much like the story of Islam worldwide but on a grander scale. With Chechen terrorist groups in Russia seizing elementary schools and opera houses, entire regions of Pakistan untamable, and Muslims populations in the hundreds of millions much of what can be said about the faith in North Africa and the Middle East can be said here but with greater intensity. Most the region’s believers are too poor or indifferent to care to offer themselves as martyrs for the fundamentalist cause, but nevertheless the passion and fervor of those who do mean that the oft-neglected Far East may be just as important as the Middle East in the ongoing War on Terror. As the oil fields present in the region are developed and the nuclear capacities of some of its states grow, this will only be more true on into the future.

India: There are approximately 1.5 billion adherents to the Muslim faith worldwide by some estimates. Over 130 million of them live in India making it the world’s third largest Muslim nation losing its second place status only recently to Pakistan. It has an Islamic population roughly equal to the entire populations, Muslim and otherwise, of Iran, Iraq, and Afghanistan combined, but despite this few know anything about India’s faithful. Part of this relative anonymity stems from the simple fact that there is no civil war in India. There are essentially no separatist groups, the struggle in Kashmir is mostly a Pakistani import and most Kashmiris wish for either complete independence from both states or to remain within India; there are no active Islamic terrorist groups in India, the recent attacks led by the upstart Indian Mujahideen being an exception; and communal violence is relatively rare for a state as large and diverse as the state of India, this in spite of a violent divide and multiple wars both past and recent against its Islamic neighbor Pakistan. Islam is by no means progressive, liberal, or enlightened in India, but nevertheless it has been remarkably peaceful in recent years.

Pakistan: After being routed in the cities and mountains of Afghanistan the Taliban dissolved into its rural towns and scattered caves, and then into neighboring Pakistan. In the Federally Administered Tribal Areas and North-West Frontier Province they found like minded neighbors, many of them their fellow ethnic Pashtuns, willing to provide shelter and support. Those who were less agreeable were assassinated in the now typical style of most militant Islamic groups throughout the world. Pakistan as a nation has for year struggled to come to grips with itself as a nation and it has in many ways been waging a smoldering civil war between its various populations and competing theological brands of Islam. In this sense the conflict with the Taliban is but one more manifestation of a larger, longer problem. Along the border various tribal groups sharing many religious, racial, and cultural similarities with the retreating Taliban long supported the mujahideen who came to fight the Soviets, then other Afghanis, and now American and NATO forces. Their allegiance is primarily to their tribes and kind, being fiercely independent, but then also to their brothers in arms the Taliban. This all in spite of the efforts both militarily and otherwise by the national government.

On another level further away from the rural border radical Islam has found root in non-Pashtun but sympathetic Pakistanis throughout the country. Political, military, and economic support is extensive and the Taliban has even reorganized itself in a variety of smaller suborganizations and political parties. Even in the government, formerly headed by the nominal US ally Pervez Musharraf, sympathizers provide intelligence and arms especially in the quasi-independent national spy network the Inter-Services Intelligence whose sometime rogue agents and generals often do as much to undermine the state’s stated intentions as support them.

Despite this extensive support, however, militant Islam continues to remain a minority belief as the tribal groups favor independence over a caliphate, majority of Taliban support continues to come primarily from the Pashtun minority suggesting political Islam will remain fused with the Pashtun nationalist movement, and even in recent elections the major radical Islamic party coalition, the Muttahida Majlis-e-Amal (MMA), rarely obtains more than ten percent of the vote.

Chechnya: Our self-proclaimed but oft-doubted ally in the War on Terror, Russia, has worked for over a decade to crush the insurgencies in the Caucasus. Insurgencies, it claims, are inspired and motivated by the radical ideologies of Al Qaeda and its leaders. This, by and large, is now true, but it was not always so. For centuries Islam in Chechnya and much of the surrounding region was certainly part of the people’s identity, but it never provided it. People were pious, but generally speaking not zealous. When they rose up against Russian rule during the fall of the Soviet Union they did so primarily as angry, oppressed Chechens, not angry, divinely driven mujahideen. The USSR under Stalin and to a lesser extent later Soviet leaders brutalized the Chechen population and the end result was simmering anger and animosity. It was these restrained emotions which led to the first civil war which yielded Chechnya its de facto independence from the Russian state. As the Chechen people were by and large not prepared to fight a war against such odds, during this period, they needed and relied upon the assistance of foreign fighters and Panislamic groups elsewhere. Like in Iraq, however, much of the native population soon regretted this decision as the Wahhabi extremists dominated and later co-opted the conflict for their wider goals of jihad in the former Soviet Union. With a significant degree of freedom secured and tensions stable, the now primarily Muslim fundamentalist leadership led the struggle into neighboring Dagestan which invited a powerful wave of Russian response. The second time around Chechnya was not so lucky and the region is once again under Russian rule. Violence still simmers but unlike in the first few years of the conflict in the early 1990s, it now occasionally erupts elsewhere in Russia in the form of large scale bombings and mass hostage taking. The conflict in Chechnya is now less a secessionist movement and now more a terrorist driven push to remove Russian influence and establish a “Caucasus Emirate” throughout the region. Islam in Chechnya is radicalizing, and we have both the global terror network and the Russian state to thank.

Islam in East Asia – Whether it be the relatively short history of the faith in the region, the fact that it is overwhelming dominant in few states, or simply because East Asians just don’t seem to make the best religious fanatics, for whatever reason Islam in East Asia, where present, in many ways lacks the heart that it possess in much else the world. Jihad simply is not as catchy despite the fact that the area holds 15 – 20% of the world’s Muslim population.

Indonesia: Indonesia is the world’s largest Muslim nation, and yet it is not part of any axis of evil, not part of any state sponsor of terror list, does not significantly export mujahideen, nor is it even a theocratic state. It is far from Westernized but also far from radicalized and is great evidence that there can be a middle way. The world’s Muslim faithful need not be either for us or against us. They can simply be boring, indifferent citizens concerned more about their daily lives than advancing the cause of either global jihad or American national security. Indonesia like just about every nation with a significant Islamic population has some groups that have mobilized politically and militarily along religious lines -- in Indonesia’s case the most powerful would be Jemaah Islamiyah which seeks to establish an al Qaeda style emirate in Southeast Asia mostly by bombing tourist hangouts -- but we should not fail to realize that these groups are often loathed as much by their fellow country men as they are by any democracy loving, freedom seeking Westerner actually aware of their existence.

Philippines: Fundamentalist thuggery at its greatest. If you want to see religious zeal transformed into little more than violent, criminal warlordism turn to the Philippines. The country is vastly Roman Catholic thanks to centuries of Spanish colonization, but pockets of Muslim predominance remain scattered throughout the island chain. These Muslim majority regions are also for a variety of reasons some of the poorer areas in the Philippines leading to an unorganized uprising of a large number of small, militant religious organizations seeking independence. The most famous of these is the Abu Sayyaf: a terrorist band consisting of a couple hundred well armed, well equipped militia and criminals whose major contribution to jihad has primarily been the kidnapping of foreigners for ransom. Although they have thin ties to al Qaeda, ideology aside their primary concern has long been the economic survival of their ransom and extortion business.

Islam in the West – Much of the present conflict is often presented in “clash of civilizations” terms where some combination of the secular or Christian West is pitted against the reactionary Muslim East. It makes for some great television viewing. It frequently, however, ignores the ways in which the two are melding. Muslim populations in the United States and Europe are increasing. In the former they are often assimilated and have obtained living standards on par with the rest of their new found society. In the latter, on the other hand, they are often politely ignored or passively oppressed leading to their continued sheltering away from society and living standards below that of the average citizen. Switching sides completely, liberal democracy and the respect for political and civil rights have made some inroads into the traditionally Muslim world. Turkey, though certainly in need of further reform, has modernized and liberalized in a way that makes it difficult to imagine that less than one hundred years ago it was still the Ottoman Empire.

Europe: There are terrorists in Europe, but there are no European terrorists. Although much of Europe has seen its share of violent attacks over the last decade it has not been by any organizations seeking to enshrine sharia law or resurrect a caliphate in places where Islam once held sway, but rather by groups and individuals seeking to punish or pressure their respective governments to behave differently elsewhere. To cease their support in the war on terror, to withdraw troops from Afghanistan and Iraq, to stop printing caricatures of Mohammed in the newspaper. These acts are often perpetrated by individuals with no allegiance to the involved state and receive no identity from its culture. They come from communities that have lived in isolation, unassimilated into their host populations. Arriving separate, living separate, and feeling separate many members of Europe’s substantial Muslim immigrant population turn to what they bring with them, their family, friends, and mosque for support and sometimes this includes radical ideologies. The population boom began with an influx of migrant laborers after World War II and has accelerated as Europe’s own population contracts with negative growth rates. Europe’s terrorism problem is in many ways a civics problem and as long as liberal Europe continues to be synonymous with white Europe the problem will likely only grow.

United States: A handful million citizens of the United States subscribe to the Islamic faith. Like most countries and America in particular they are a diverse lot. Recent studies and opinion polls, however, indicate that on average most American Muslims are middle class, fairly well educated, and only recently immigrated. Perhaps alarmingly a sizeable portion, about 47%, claimed they considered themselves Muslims first and American’s second according to a 2007 survey. Additionally, amongst the younger parts of the population up to 15% supported the idea of suicide bombings against civilian targets in the defense of Islam in some circumstances. These worrisome statements noted, it should also be known that roughly an equal number of Christians in the United States say the same thing concerning their priority of faith over state, and when the same poll was posed to Americans in general (with references to suicide bombing and Islam removed and the statement more general) an even greater percentage of Americans, young and old, felt the bombing of civilians was at least sometimes justifiable. There very well may be sleeper cells in our midst, but when phone surveys and sociological studies are presented by pundits in the media to suggest evidence for a subversive fifth column of dastardly Muslim Americans amongst us it is best to keep in mind the clunky nature of such studies.

Turkey: A secular state by its constitution, part of NATO, seeking to be part of the EU, and almost 99% Muslim, Turkey exists in many ways as the next step in what the West wishes the East to be. Both democracy and Islam are alive and well often, perhaps surprisingly, serving to reinforce one another. The Justice and Development Party, Turkey’s main religiously based political party (though unofficially so), has grown stronger as the threat of a direct coup by the secular military wanes, but it is also the Justice and Development Party which is currently one of Turkey’s biggest champions for joining the EU helping to push forward many important reforms which have helped control long standing inflation in the country. Claims are often made that Turks are not “real” Muslims as they tend not to be as conspicuous in their faith as many of their neighbors, but nevertheless polls have consistently shown that most Turks believe religion to be “very important” to their lives.

The End? – In summary, closing, and conclusion: it’s complicated. The war on extremist Islam, more formally known as the War on Terrorism, covers dozens of countries, deals with different ethnic groups, languages, histories, and cultures, and is involves a multitude of actors with wildly varying motivations. Nationalism, racism, politics, tribalism, economics, survivalism, and petty hatred all have as much influence if not more in differing parts of the world. To lump them all together in order to fashion a convenient sound bite or trite war doctrine is foolish and dangerous. In complex cases we must resist the urge to muscle through dismissing some facts here and arbitrarily grouping other unrelated facts there in an attempt to quickly establish order. All of Islam is not our enemy. All of Islam need not be our enemy. Despite their unifying religion, varying creeds and differing cultures, politics, and histories make all the parties to the conflict worthy of their own nuanced approach. A little bit of tedium in the short term to correctly identify threats and recognize potential allies is what will carry this war. When things get murky it will be essential that we fight smarter and not just harder.


Ok. End diatribe. And now for something a little more peaceful. Finally, here are Rachel's photos of our trip to Greece some five months ago.

Friday, September 5, 2008

Conventions Again: The Brief Version

I watched yet another national political party convention tonight. The Republican convention staring John McCain and Tina Fay. I hear this McCain character's something of a maverick. And a war hero to boot. Why doesn't anyone talk more about this?

Once again I decided to alternate between CNN and Fox News to compare coverage and once again I must reiterate that these comparisons are neither standardized nor scientific, but simply what I saw whenever I changed the channel which was roughly whenever I felt like it. It seemed that format wise both were as they were previously. CNN had a large contingent at the convention itself and presented the convention in essentially the same manner and style. The commentators for their part also discussed things in the same way as before. They did seem a bit snarky at times, especially in the beginning, but this seemed to give way some after McCain himself arrived. Fox News likewise was much as before the main exceptions being that Sean Hannity of Hannity and Colmes was noticeably quieter in the beginning and the network, for whatever reason, decided to have its own host of reporters inside the convention itself for this go around as well. They had mostly pleasant things to say. Lastly, both stations forgot to mention Obama's full name this time around. Barak Hussein Obama. How else are we going to differentiate him from the other Barak Ombamas?

Oh and instead of an endless stream of fireworks the Republicans had an endless sea of balloons. I hear the Libertarians had an extensive network of fog machines. The Green Party, for what it's worth, could only afford a few canisters of silly string.

The conventions themselves aside I was once again pleased. This year is a good year to be a voter.

Thursday, August 28, 2008

I'll Vote for You, and You, and You

Tonight was a slow night on television. Which for me essentially means there was no Wipeout, American Gladiators, the Office, or noteworthy cartoons on air to watch. As a result I found myself tuning in to watch the Democratic National Convention. Curious, I switched back frequently between CNN's broadcast of the program and Fox News's broadcast. Not surprisingly there were differences. Although I cannot say this is by any means a comprehensive or even fair assessment of the two shows -- there was little rhyme or reason to when and why I changed channels and there were no standardized, scientific measurements of bias -- but the atmosphere for great parts of each presentation was clearly, significantly different. CNN gave much greater coverage of each stage of the convention where as Fox News frequently looped back to Sean Hannity who aggressively and incessantly attacked Obama as he is want to do. CNN's commentators, it appeared at least, got more caught up in the pageantry and excitement of the convention than Fox's commentators who seemed much more detached. (Likely having something to do with the fact of where each set of reporters were located: many of CNN's at the convention and many of Fox's outside it.) And where as CNN referred to Obama simply as Obama, Fox News took the time to clearly enunciate his full name, Barak Hussein Obama, at least once. Hmm. Alright. I look forward to watching the Republican National Convention next week.

I look forward to watching the Republican Convention for other reasons too, however. Better reasons. That's because for the first time in my short tenure as a registered voter I do not feel as if I am voting for the lesser of two evils. I do not feel as if I must grugingly chose between two leaders who will both likely lead us into mediocrity at best or calamity at worst. I am, for once, not tempted to vote for Nader. I am, I am surprised to say, happy with not just one candidate but both candidates. This is not to say I fully agree with both Barak Obama and John McCain. That is of course not even possible. I disagree with both of them on many things and on many things I agree with neither. They don't have all the answers like do. But I do feel that both men are honest, hard working, and intelligent individuals earnestly striving for what they believe to be the best for their country. In a country where politics is all too often politics and little more, these two men, I believe, have remarkably, truly, put their nation first. I was not intending on watching the Democratic National Convention, and certainly not on writing about it, but after watching a good share of it and observing McCain's congratulatory commercial I felt led to. Partially just to make a Nader joke, but mostly to record one of the few times I have been particularly excited to vote for the next president of the United States. Many people have often considered my views on the world negative -- I won the "Most Cynical Award" on my high school college trip -- but I have always felt myself to simply be a realist. And now, for once, I am really happy for our next chief executive. Whoever it may be.

Tuesday, August 26, 2008

Suck it, Emirates!


If I may be profane for a second.

Thank you.

Finally! After some six months of continuous effort, multiple phone calls, two parcels, and over ten emails I have, finally, received my reimbursement check from Emirates airlines for causing a missed flight and having to pay to reschedule! Finally! $100 for me! Generally I am all about fiscal responsibility -- maybe buy myself a nice US savings bond or invest in a mutual fund I'd say -- but, now, I think I may just spend it all on booze and loose women. Just to spite them. As much as a faceless, global corporation can be spited at least. (In all respect the company personnel were always very cordial and nice. Just slowly cordial. Very, very slowly cordial.)

So maybe I'll trick out my new bike. Maybe a horn? Gratuitous reflectors? Those rainbow colored click clack things you stick on the wheel spokes?

Wednesday, August 20, 2008

A Bit of a Cat Problem


I wade through cats when leaving the house towards work in the mornings. Cats waist high, fifty felines deep; it's a bit of a problem. Thanks to the generous daily donations of food and water by our next door neighbors the local tabby population is expanding rapidly and will likely soon blot out the sun. With cats in such tonnage also comes kitty waste, and that's also becoming something of a problem. For my roommate at least. Although I am not so fond of our not dog friends I do not terribly mind their presence all too much. Laura, on the other hand, seems to have a far more sensitive nose and far less patience. Generally speaking she's a fairly calm and collected person, but under the guidance of her parents who visited recently she has begun a war of attrition aimed at ending the scourge that is stupid, skittish, feral cats.

The solution, initially, consisted mostly of bleach. Lots of cleanser to cleanse the urine smell and burn the lungs of any animal lingering too long on the porch. Our front door briefly no longer smelled of tom cat tinkle but instead like a very heavily chlorinated pool. This was only the opening volley, however, in what was to be a bleach, moth ball, and ground black pepper triple offensive, and the very next day I arrived home from work to find a generous scattering of little white spheres throughout the front yard planters. It kind of looked like it had recently hailed had it hailed only quarter inch sized balls of ice, but the pungent smell of ammonia replaced the chlorinated pool smell making it obvious it was the moth balls. Is it working? I am not sure; I have been headed to work later the last few days and generally speaking the cats scatter to go about their cat business shortly after sunrise, but I believe the Gallos are stockpiling mustard gas just in case.

Unrelated to the current arms race, I took the USMLE Step 3 yesterday and the day before. That's all I got to say about that. If there's any secret police more feared than the HIPAA brown shirts its the Federation of State Medical Boards Stasi, and I fear I have already said to much.

Doubly unrelated, I bought myself a new mountain bike with my economic stimulus check. A 2008 Specialized Rockhopper! Yeah. Awesome. Basically it's a bike, and it's blue. The rest is all kind of muddled. There are apparently about 2100 different mountain bikes produced with varying ill-defined features, and I am pretty sure I purchased the Rockhopper mostly because I just subconsciously thought the name was outstanding. Anyways, consider the economy stimulated! I've done my part Mr. President!

Saturday, August 9, 2008

Driven to Drink

Another week of clinic and another week of working late secondary to patient problems in the head. This time it was anxiety and panic. An otherwise uneventful morning clinic was made a good 2 to 3 hours longer by the theatrical shenanigans of one young patient who, medically speaking, was freaking out. This manifested itself mostly through exaggerated breathing which was entirely unnecessary as even when we slapped him across the face with some Ativan and his respiratory rate dropped into the range where the rest of us typically like to breath he continued to have excellent oxygen saturation of his blood. Unfortunately, the fact that his oxygen sats and vital signs were pristine were of completely no relevance to him as he continued to complain of anxiety, shortness of breath, and so on. Why did he feel this way? Who the hell knows. He couldn't say. Why was he still complaining of shortness of breath when he clearly was not short of breath any longer? Beats me. He couldn't say. How was this at all in any way different from the panic attack he had had only two months before in the emergency room? *Shrug* He couldn't say. He just knew something was amiss.

Of course there wasn't. He was just having a panic attack and all this was both consistent with panic attacks in general and past panic attacks that he had himself experienced in the past. We'd done a thorough cardiac and neurological exam, even, probably unnecessarily, ordered an EKG and looked into the possibility of a pulmonary embolism of which he had no evidence for, and we found nothing. Unfortunately, I am not yet confident enough in my nascent physician skills to say, "hey, buddy, get out of my exam room already!" and so we gradually titrated his Ativan till clinic ended, my supervisor came in to take a peek, and we gave him the choice to go home or to go to the ER. Next time I think I'll try grabbing his shoulders, shake, and exclaim, "get a hold of yourself man!" Maybe I can get a clinical trial published out of this.

And so now I drink. Not alcohol so much -- I still generally don't care for that -- but I have taken up coffee. These long hours and frustrating patients mean drinking tea three times a day will not suffice. Who wants to drink that much tea? Certainly not me. The alternative caffeinated beverage list included coffee and soda, but as the idea of a cold Dr. Pepper at 0700 did not sound terribly appetizing I decided to turn to coffee. I had never really enjoyed coffee in the past, but it turns out with a couple creamers and a couple sugar packets most things taste better. Unfortunately it seems even the added caffeine boost of 16 oz of generic Wilford Hall coffee cannot sustain my attentiveness any longer than the actual drinking of the beverage itself which makes me think: maybe it's just the act of doing something during lecture which helps me stay awake? Maybe I just need to keep busy somehow instead of passively listening/staring/dozing off? Maybe I should try milkshakes? I'll stick with coffee and tea for now, but if things continue on it may be milkshake time. And after that? A fifth of jäger? A nice club soda?

Saturday, August 2, 2008

Internal Medicine with a Minor in Psychology

My clinic doth run over.

Officially each office visit should take 45 minutes of my time. Recently, however, this has not been the case. Instead I will have three or four 50 minute appointments and one drawn out and draining 1 hour and 15 minute one. This is not because I am just that thorough and kind hearted. But rather because my patients all seem to have a touch of the crazy.

Sometimes it's fibromyalgia with the patient reporting pain here, here, and here. Some pain there radiating back to the first here and sometimes becoming the second here. And that place over there has two types of pain. Oh and my hair hurts.

Sometimes it's chronic fatigue syndrome. Or myalgic encephalomyelitis as my patients like to call it. Or yuppie flu as I like to call it. They aren't the actual patients, their sick relatives in need of custodial care are usually who the visit's for, but patients' families can just as often be as much part of the problem as part of the cure.

Then there's the standard old major depressive disorder. Patient wants to kill himself, doesn't want to talk to anyone about it, and doesn't want to leave the exam room. Of course he didn't come in for depression. No, you cannot get a medicine appointment for a psych complaint. Instead you gotta be sneaky crafty. Don't want to ruin the surprise.

And lastly there's the undiagnosed bipolar patient talking incessantly, not answering questions, and generally providing no relevant information about his ailments to do either of us any good. Feel free to leave before I return from consulting with the staff physician about your diagnosis. It's not like you came to the clinic for medical care because, actually, I am still not sure why you came to the clinic today.

All in all it makes clinic interesting and for me leaving the hospital at 1900 or 2000 at night. The immediate frustrations aside I do not mean to convey that I dislike psychiatric patients -- and two of the disorders aren't even psychology related really. Crazy people are people too after all. It is just that I don't have enough time to take care of all the problems which actually threaten life and limb let alone the hours extra needed to take care of the problems brought about by bad humors and forest gnomes. I am training to become an internal medicine physician but to date it seems my end expertise will be that of a psychologist / orthopedist who occasionally dabbles in the diabetes and the common cold.

***As a general disclaimer: though I in general like to try and be an honest guy, with all the rules these days and the rise of the HIPAA fascist state I must resort to vagueness, generalizations, and outright lies when it comes to recounting my patient stories. Don't want to breach any privacy here and I definitely don't want a summary execution without trial.***

Sunday, July 27, 2008

Ready, Set, You're Late

One of thirteen blocks for intern year complete.

Thank goodness.

In summary this is what the last month was like. I was given five brief lectures by five different individuals only three of which clearly pertained to my upcoming medical career and only one of which was delivered by anyone with a clear command of the English language (and it wasn't for one of the pertinent lectures.) I was then dressed up in costume, asked to spin around with my head on a baseball bat for two minutes, and subsequently thrown into a task I had spent many years hearing about but not actually pretended to practice to any great extent for over half of a year. They then kept me awake for 30 hours straight and upon my discharge told me I was doing it all wrong.

Ok, so there's some hyperbole there, but I will say overall life has not be pleasant. Of course this was to be expected. It is not intended to be pleasant. And so I keep telling myself this. Thankfully the disorientation and periodic despair are resolving as things settle and become routine. The military did -- in my own opinion and in the collective opinion of the intern class -- a poor job preparing us for the practical aspects of our work in the military setting, and I did a poor job of preparing myself during the fourth year of medical school for the practical aspects of caring for patients. So there's been some catch up. Now, however, the main problems are, and will likely remain, ignorance and inefficiency. It seems I do not know much and what I do know I do slowly. But, as stated before, this is to be expected. Hopefully at some point I will find a way to resolve them. Currently I am thinking more caffeine and perhaps some methamphetamine.

Medicine wards at Brooks Army Medical Center (BAMC) was, with rare exceptions, not fun. Overall I had a good team of resident, attending, and medical students, but I will not miss any of them. Much like Commissioned Officer Training was a hectic, unpleasant, but ultimately educational (sort of) experience, the last month has been a kick in the pants and a kick in the balls, but kicks that were both probably needed. Now it's ambulatory month so four weeks of two day weekends! Few things elicit a smile as much as the idea of a two day weekend does. Either this is an indication that I have found satisfaction in the simple things in life or I currently have only simple things in life to provide satisfaction.

Anyways, life goes on. Good times are still occasionally had. The Olympics are coming up. I am relatively content.

USA! USA! USA!

Friday, July 18, 2008

He Eats Mostly Milkshakes

There are few joys in the life of an intern. One's days consist mostly of recording an endless sum of data, transcribing an endless number of notes, returning an endless stream of pages, and laboring endlessly in the hospital's endless bituminous coal mines. It is infrequent when one can smile and if you smile too long they call it mania and start you on depressants. One consistent joy, however, has always been stumbling upon the curiously written statements of other physicians. (Yes this is what goes for joy these days.)

For medical and legal reasons everything must be documented meticulously. Sometimes, however, well, there just ain't time to do it well. As a result well crafted statements succinctly conveying information are often replaced with whatever thought first enters the physician's mind which, to him at least, conveys what it is he's trying to convey. The vast majority of times this is sufficient. Some of the time, however, it just doesn't quite come out right.

In one recent event concerning an elderly, fatigued patient of ours, the consulted hematologist-oncologist wrote a quick one paragraph statement discussing the nature of the man's pancytopenia. After briefly describing the patient's signs and symptoms in the standard medical jargon he writes in a new sentence, plainly, "The patient states he eats mostly milkshakes." He was trying to convey that the patient was malnourished and so lacking in the vitamins necessary for adequate blood production, but all I could think was, "that is awesome. He really does enjoy his milkshakes." This was, incidentally, a miscommunication -- the patient had informed us earlier that though he did indeed love himself some milkshakes he actually ate microwave dinners from time to time as well -- but nevertheless that's what was recorded and that's what everyone will be forever reading when they go through his medical records. I can only imagine what will be recorded by future physician robots of me. Probably something like, "The patient states he eats mostly sandwiches. Patient perseverates on the idea that he makes quite possibly the best sandwiches in the world discussing the matter at length. Consider psych consult."

Speaking of eating nothing but milkshakes, my diet is actually not too entirely different right now. With no established lunch time and about 14 hours of work for an 11 hour day lunch is often cast aside and you eat what's nearby. Hopefully it's edible. For this last week it's been:

  • Sunday: Half day, I made a sandwich. Possibly the best sandwich in the world.
  • Monday: On call. 1100 ate some beef jerky. 1300 ate some dried strawberries. 1600 ate grilled cheese, fritos, and a Cherry Coke.
  • Tuesday: Post call. 1400 made a sandwich. Possibly the best sandwich in the world.
  • Wednesday: Off, I made a sandwich. Very likely the best sandwich in the world.
  • Thursday: Normal work day. 1400 ate two bags of fritos and a 7Up.
  • Friday: Normal work day. 1400 ate grilled cheese, chili mac, Ruffles, and a Barqs Root Beer.

And that's a good week. The pinnacle so far, however, has been the Tuesday prior when my lunch consisted entirely of a strawberry cupcake. At first I was worried I'd lose weight and become questionably anorexic, but it turns out the caloric intake of cupcakes is about the same as a regular meal. I'll just end up pancytopenic someday.

On a separate note. My long call last Friday resulted not in sixty new patients -- I cap at five new ones in most circumstances and so was done admitting new patients around 11:00 pm -- but it did have about sixty cross cover pages to take care of. I have been jinxed; I have been humbled.

Wednesday, July 9, 2008

Fair Weather Ahead

There are certain truths concerning medicine that are kept from the general lay public for the public health benefit. Mostly their peace of mind -- not so much their actual morbidity and mortality. One of these truths is that July is the best time to be killed by your doctor. Ninety-nine percent of residencies begin in July and all the fresh new interns -- most of whom know less than they did than as even fresher third year medical students -- combined with fresh new senior residents -- who were themselves only a year ago fresh new interns -- mean that the chances of you getting worse from your hospital stay are almost as good as you getting better. The same hand extended with an awkward smile to greet you on the gurney may be the same hand making the sign of the cross while pronouncing your time of death.* I imagine these statements won't actually hold up to statistical analysis thanks to excellent supervision, but it's a medical truth! It is so.

Another medical truth is that there are some physicians that bring with them them the storm clouds of disease close in tow, and then there are some physicians who are bathed in a gentle light of health bringing peace, refuge, and pockets full of medicine wherever they go. Black clouds and white clouds. So far, after two calls, it seems I am a white cloud. Not through any effort on my own part mind you; no one knows how the Gods decide the status of each physician. It is theorized that they either draw lots or simply look down from their collective ivory towers and name off the first few people they see, but whatever the means, once ordained it is unshakable. In my one and a half weeks of residency I have admitted three patients on two call nights and taken care of perhaps another three. This is less than what many teams see in a single call night. Sometimes I lay hands on patients and they get better, blow kisses at children so they'll stop crying, and wink at the elderly so as to resolve their dementia. None of this ever works of course as that's not how the black cloud/white cloud system operates, but I like to do it nevertheless.

And the last medical truth I will share with you all is that most medical truths are contradictory. Some may like to use the term "paradoxical," but, no, they're usually just contradictory. And as we residents are a superstitious lot it is likely that by mentioning my white cloud status just now I have successfully jinxed it. I am on call this Friday. I am expecting sixty patients.

*Actually I don't think most residents make the sign of the cross when pronouncing people dead. Except for maybe the Catholic ones.**

**Is this Catholic racist?