More C4

The real test of a medical unit's combat readiness comes not in their mock platoon marches or field training exercises nor in their mastering of the Advanced Trauma Life Support (ATLS) classes. It doesn't come in the twenty-four hour hutment confinement due to training being cancelled on account of freak San Antonio snow. It's not even whether they can go to the communal showers and strip naked and wash and rinse all while avoiding prolonged eye contact next to one another which successfully tells whether they can successfully carry stretchers through mine fields together. The real test of a real unit full of real men comes in the commode.

An Army Strong platoon in today's Army of One can sit down, relax, and watch each other go number two. That's the short of it. That's the test of a unit's combat grit. And in light of that profound military truth, we, collectively, failed. The test as it was ingeniously crafted comes from the bathroom's design as all the stalls, which are for whatever reason already spaced unusually tightly together giving you little in the way of elbow room, were, to perhaps make you forget you had nowhere to place your elbows, also freakishly close to the opposing row of stalls immediately across the way. And lest you pause to think too long about the fact that you could probably touch knees with the guy across from you were he to be a particularly tall individual, you realize that in fact you could touch his knees -- and perhaps gently caress them -- because there are no doors to any of the stalls. There is nothing but open space seperating you from the guy and white cinder block walls of the toilet across from you. A real hero -- I believe the Army was suggesting -- will sit across from his battle buddy, stare him deeply in the eye, and engage in friendly banter while taking a dump. He may even whistle a patriotic tune. Discuss the latest tourniquet application techniques maybe. Thumb wrestle. Whatever exactly is supposed to take place while two dudes respectively sit across from each other in a race to finish their business first, the end result is inevitably a crisp salute and a new level of unit cohesiveness.

Finding this to be the worse of two options were the other option to be small bowel obstruction followed by colonic perforation from never using the restroom again, we collectively came to an unspoken modus operandi. As there were four stalls in each row of the livestock pen the first person would use one of the stalls closest to the far wall while the next person would use the stall furthest from the far wall. Each successive soldier could use neighboring stalls if facing the same direction and feeling friendly, but this was known to be discouraged. Under no conditions was it acceptable to sit immediately across or immediately diagonal to another toilet user, and it was punishable by death if you accidentally sat on someone else's lap. If you were to arrive and find the maximum occupancy of four out of eight stalls in use you would politely return later, you didn't need to go that bad. If you did need to go that bad, congratulations you now know four people who hate your guts. In the end it proved successful -- I never had to watch what God never intended for us to watch -- but our esprit de corps suffered as we lacked that I've-seen-you-poo level of commitment that only veteran, battle tested units ever possess. We may have technically passed the training but we failed each other. C4's most dangerous landmines were truthfully not the literal landmines but the I-don't-want-you-looking-at-me-like-that landmines deep inside ourselves.

We were then forced to do jumping jacks in gas masks and hazmat suits, which -- coincidentally -- is a good way to induce fainting and general claustrophobia-related freaking out.

They're Practically Giving It Away!

It's time to get tough on aid.

Every year the United States hands out billions, probably trillions, of dollars freely to whoever asks for it. Want some cash, Greece? How's $25 billion sound? Need to build something, Morocco? Build a thousand of 'em, here's a million. Got problems, Nepal? Oh yeah don't we all, let's see what forty mill will do for ya. Surprise me. It is a well known fact that the US spends, like, what, at least 10% of our federal budget on foreign aid every year? Maybe even 20 or 30%, I don't know. It's just probably a lot. And what do we get for it? Nothing but nothing. It's time America got what's hers.

That's why I'm happy the GOP presidential candidates are finally standing up for fiscal responsibility. I appreciated it when Rick Perry stated that every year the foreign aid budget would start at $0. And I loved it when Bachmann demanded a song and dance from every ambassador requesting assistance while she would use the ambassador's attache as a foot stool. Gingrich's statement that he would respond to every aid request with, "explain to me why I should give you a single m---- f----- penny," was the kind of frank diplomacy we need in the world. That's always been the whole problem. We just give these guys a blank check, have them fill in the zeros, and then never talk to them again until the following year's aid dispensation party.

It would be one thing if these countries helped us out by, like, assisting with our antiterrorism efforts or making peace deals and cooperating with Israel, or even if doing good deeds like eradicating infectious disease was still it's own reward, but that's not happening and it's not. Pakistan hasn't arrested a single terrorist and I'm pretty sure their army and the Taliban probably totally hang out and watch cricket together on the weekend all the time. Plus as Senator Santorum pointed out, "if we solve all the world's problems then they'll never learn to solve them themselves. As the saying goes: If you give a man a fish he'll eat for a day; if you teach a man to fish he'll eat for a lifetime. And then cripple your domestic fishing industry so we probably shouldn't do that either." Plus it's not like the world's got a monopoly on poverty. I only make $32,000 a year breaking my back, putting in long hours. I don't even take all my sick days! I know as an American what's poor here ain't poor everywhere, but I bet that's not too far from the global average. I imagine I could kick back and watch a game with some dude in Ubeki-beki-beki-beki-stan-stan while we share a few Buds.

Diplomacy isn't easy, but it ain't rocket science. Until we can get everyone to finally start wearing their "friend" and "enemy" badges liked we've asked -- and get them to stop trading the damn things around -- we should at the very least demand an accounting for our charity. And a return on investment. With a nice letter of thanks. And maybe a gift basket. Containing the hand written thank you notes of children and the drilling rights to offshore oil deposits. Just a small token of appreciation with cash value equal to or greater than that which we have so freely given.


In other news, despite the American public's perception that around 25% of the federal budget goes to foreign aid in fact only about 1% ($37 billion FY 2010) does which is less than the approximately 5% ($185 billion FY 2010) of the federal budget spent annually on national debt interest. Although a little over $1.5 billion went to Egypt last year, $4.2 billion was spent on assistance for refugee populations and $9.8 billion was spent on the President's Global Health Initiative started by former President Bush to help combat HIV and other infectious diseases in developing nations. The median US income in 2007 was $25,076 and placed one in the top 10% of global wage earners. Justin Bieber is set to marry Kim Kardashian in next year's wedding of the century.

Doctor I Have a Disease I Just Invented

The first few weeks of fellowship I saw a fair amount of Lyme disease which, being from Texas, was like a cool, exotic infection I'd only previously read about. Neat. The last few weeks of fellowship, however, I've been seeing a lot of chronic Lyme disease which, being a made up condition, has made me accordingly increasingly sad.

There are a lot of unfortunate, difficult to treat diseases that exist in the world: dementia, sciatica, fibromyalgia, the crazies; but for the most part there's little debate whether these are true disorders or not. Whether you believe the primary problem in management is organic or more pyschosocial isn't so important as in either case you can at the very least categorize it, label it, and provide a foundation upon which you can work with your patient. Fibromyalgia, the wackiest of them all, even has research proven therapies which can help, sort of, if anyone would ever cooperate with a physician's recommendations. Chronic lyme disease, on the other hand, is a disease that in all reality doesn't even exist. There is in fact no such thing as chronic Lyme. The patient may as well just tell me a woodland fairy placed a curse on them so I could at the very least reply with, "that's impossible. Woodland fairies don't know any curses. Only marsh fairies cast spells. Jeez." Instead I am left with either "get out of my office," or "interesting, tell me what's been going on."

The clinic appointments for these unfortunate souls inevitably becomes an endless list of various, mostly subjective complaints followed by a review of systems I wish I didn't have to go through. Everyone's abdomen will be tender. Everyone's joints sore. Everyone's blood work and imaging are completely normal. Sometimes they are at the very least a little creative with their complaints -- something I do appreciate -- but even if you can get a patient to admit that a particular symptom is getting better it is often quickly pointed out that it's only because it's about to get much, much worse. "Blue tongue you say? It doesn't look blue now." "Yes well it's not blue today." "So it's getting better?" "No! Why would you say such a thing?!" The worst part inevitably comes at the end when I must decide how I want to tell them they're full of it. Despite various approaches I have yet to find the reply that yields a grateful smile and gratitude for the visit. I am finding it is often enough easiest just to defer the conversation to my staff -- who I have to discuss the case with regardless -- who with his years of experience can tell patients there's nothing we can do for them in a very polite, scholarly, and time efficient manner.

If it weren't for the fact that most these people are otherwise good folks who are eagerly trying to figure out why they feel like crap literally all the time it would just be perversely funny. Because of their various personality disorders and tendency to believe whatever lunatic site they found on the internet over a trained specialist who can explain to them why chronic Lyme is nothing more than heavy metal induced insanity, however, I can often only extend so much sympathy. In the end the best solution may just be to give them what they typically want: an endless supply of medicine.  That's why I am actively working on a cure with the Willy Wonka Pharmaceutical Company. We hope to have a twelve month supply of prescription strength Sweet Tarts Lyme Zapper! ready to go by winter. Due to the unforeseen tastiness of the cherry and green apple formulations leading to production shortfalls, however, it'll initially only be available in grape. Thankfully that's the strongest flavor. Unfortunately it's also the most expensive. And the kind that gives them cancer; I read it on the internet.

I'll Save You!

About a year ago I partook in the military's Combat Casualty Care Course also known as "C4." A week long academic and field training course designed to prepare us for combat medical care as it is provided in the first and lowest echelons of care from the battlefield itself to the first triage and staging areas such as the Forward Operating Base (FOB). In summary: it was cold. The rest of the details I may or may not eventually get to later, but first a story.

Much of our practical field training consisted of forming up in our platoons (see below) and undergoing marches which would take us into various situations where invariably someone's legs would be blown off. Each platoon was broken down into four security teams (X1-4) which provided security and two litter teams (L1 and L2) which provided the actual medical care, collected blown off limbs, and carried the stretchers. All teams had individual leaders (marked by *.) The entire platoon itself was additionally headed by a platoon leader (P). A march would begin in two columns with two security teams in the back and two in the front, the litter teams dispersed somewhere in the middle. It would inevitably end with the litter teams running about in varying degrees of order or chaos while the security teams provided some degree of perimeter cover -- or, as in this last case, just watched the mayhem with an amused curiosity. The missions always changed in detail, but they always consisted of a march to an objective, an attack by our various training instructors (TIs) on the platoon, and people getting their legs blown off.

X1 X1 X1 X1* L1 L1 L1 L1* X2 X2 X2 X2*
P
X3 X3 X3 X3* L2 L2 L2 L2* X4 X4 X4 X4*

Two columns of two security teams and a litter team each form a platoon. Or a bunch of random letters.

After the initial orientation and a few dry runs where we mostly just stared at each other in confusion, the majority of our exercises went off relatively well. The first where I was leader of litter team one was uncomplicated thanks to my impeccable leadership skills and, more likely, simple luck and good fortune. The latter exercises also went off without too many casualties save one surgical intern who had a helmet dropped on her head after stepping on a land mine. The helmet was real, the mine just covered her entire left side in red dust which would never come off. Our second mission, however, was a colossal failure, but for those who were there watching it all unfold as part of the perimeter security teams -- of which I was one of them -- it was like staring at a slow moving, never ending train wreck of comedic folly.

The mission as described was to find a downed C130, locate casualties, secure the scene, and evacuate the wounded. Pretty straightforward it sounds, but not so much in action. At least for us. After a short march we reached our designated stop point where our reconnaissance team was sent to evaluate the scene. After returning with the information of what they saw the team leaders and platoon leader collectively deliberated for a number of minutes before coming up with the simple plan of sending the two front security teams to secure the perimeter alone while everyone else just sat back and waited. That was it. No more plan than that. Not surprisingly it all started to fall apart when 5-10 minutes later we began to hear gunfire and explosions about a half mile down the trail where our forward security teams had so nobly previously wandered off to.

Not having any contingency plan for what to do in case of explosion we briefly fell back to the tried and true action of staring at each other in confusion for a few seconds before we all made the collective decision to simply get up and run as fast as we could towards the scene of the action. So off we ran, all sixteen of us in two rear security teams and two litter teams and all in various states of disarray, not entirely sure where exactly we were going or what we were to do when we got there.

We arrived to find a half erected security perimeter set up around a lightly smoking C130 and a few ramshackle cement houses all surrounded by the scrubby trees and dust which make up the majority of south Texas. Carrying only our plastic rifles, canteens, and the same Kevlar helmets and flack jackets that everyone else had, my rear security team passed by the column's litter team in an attempt to complete the half ass parameter that was already in place before they got there. This placed me immediately adjacent to the C130 and privy to all the action which was about to unfold.

The litter teams arrived shortly after we did to what was still a relatively unexciting scene of smoke, sound effects, and people lying around with rifles staring off into the trees pretending to provide cover. One litter team diverted off into a gully on the left to assist some wounded there while my column's litter team headed directly to the right to the downed C130 where, presumably, the bulk of the wounded would be waiting. This latter team, litter team 1, was composed of a motley crew of four: one young, fit, and tall male Army nurse; one young, fit, and tiny female Navy nurse; one older, overweight, and enthusiastic Army physician assistant (PA); and one very old, very huge, and very Colombian Army nurse. Together they approached the smoking aircraft in a disorganized run, but whereas most the team slowed on approach, the PA ran full steam ahead into the back of the craft GI Joe style yelling a heroic, "I'll save you!" This was followed by a loud bang from deep inside the dark aircraft and all went silent.

"I've been shot!"

"Who is it? Where are you?"

"It's me! I've been shot in the chest!"

"How do we know it's you? .... Who won the 2007 Super Bowl?"

"How the fuck would I know! Come get me out of here!"

So went the back and forth between the faceless voice in the front of the blackened plane and the skeptical litter team waiting reluctantly outside the ramp doors of the back of the craft. Finally, either sufficiently persuaded or for lack of anything they could think of better to do, they decided to go in after him.

*BOOM!*

Immediately after their collective decision to enter the C130 the two hundred pound Colombian Army nurse stepped on a land mind placed right outside the plane and was out of action. Within just a few minutes litter team one was down from four medics to two.

"Ahhh! My leg! I lost my leg!" screamed the Colombian clearly enjoying the opportunity to pretend to be wounded as he rolled around the loading ramp of the airplane. His comrades attended to him and began applying tourniquets as taught while he continued to thrash about as imaginary blood loss led to imaginary hysteria. Their task was not made any easier by an impressive size differential as the remaining medics had over a one foot and hundred pound size differential between them. The platoon leader who had been supervising attempted to instruct them towards cover while simultaneously seeking assistance from litter team two who had just recently secured their wounded in the gully. He had mixed results.

Treated but still lying exposed outside the airplane, the bulging Colombian Army nurse was left to wait while the two man litter team one went back into the smoking darkness to retrieve the rest of the injured. The explosions around the landing zone had mostly tapered off by this point, but the sporadic gunfire and incessant yelling from the TIs who offered mostly unproductive or entirely terrible advice continued. The platoon leader continued to shout instructions most of which were either unheard or unheaded. Around this time litter team two came to assist. Not sure of what was going on exactly and hesistant to act they loitered outside the plane.

*Crack!* *Crack!* *Crack!*

Fed up with the chaos and clear lack of command and control, the TIs decided to add to the situation by having one of the newly arrived litter team's legs shot out. Counting the PA still in the front of the plane, the Army nurse bandaged and bleeding outside the plane, and three more disfigured mannequins in the plane itself there were now more wounded than medics. What order there had been completely fell apart as the medics attempted to carry, drag, and pull whatever wounded they could to any semblance of cover available. This was made all the more difficult by the fact that the inside of the cargo jet had been heavily coated with fake blood for the fake bodies. When the medics emerged they would as often as not be covered in as much or more blood than the mannequins themselves, and frequent stops were necessary to reposition and regrip the slippery wounded. The inability to effectively move the heavily lubricated mannequins eventually earned them the term of endearment, "greasy Ken dolls." One more land mine went off, and the mission was over.

The post-mission debriefing was an unhappy and frustrated attempt to explain what exactly went wrong -- essentially everything it turned out -- and what could have been done better -- maybe not step on so many land mines? It was an excellent example of how not to execute a rescue mission which was not too much of a surprise considering none of us had ever done anything at all like it before. I'm not entirely sure if I was supposed to leave my post on security to assist with the moving of bodies, but it likely would have just led to my legs getting blown off. In either case it was an amusing story since in the end we all kept all of our limbs. "I'll save you!" became the catch phrase for our platoon and the battle cry for all further field training during the course.Thankfully no further mannequins had to lose their lives in rest of training.

Uhoh!

Two weeks ago my parents came for a visit. Just a few days ago they left. I'm still finding random objects left behind. Whether to call them gifts or not varies depending on the object. Today's gift: two umbrellas in my closet! Awesome, I've been needing an umbrella for oh... about four months now? The black and white checkered dress shirt distinctly suggestive of a picnic table cloth on the other hand I thought I had disposed of before they left.

Their visit though somewhat lengthy by the standard of most visits to small town, middle of nowhere, went surprisingly well. There was the requisite major family argument about whether or not the October Nor'easter was going to end life as we knew it on the Eastern seaboard or not, but that aside it was a remarkably pleasant two weeks. Much of it was spent watching a great if not eventually disappointing World Series or making trips back and forth from Price Chopper with various things to stick in my fridge. Such as a six pack of Romaine lettuce heads which I will hold onto until the gigantic-salad-composed-of-nothing-but-lettuce craving kicks in. And when it does I will have two different flavors of salad dressing to chose from. Or A1 steak sauce. Or Worcestershire sauce.Or an industrial sized bottle of ketchup.

The rest of the trip was divided amongst road trips to Woodstock, VT; Burlington, VT; and Seacoast, NH. The only one of these worthy of note was the last as it was both scenic and complete with a trip to Markey's Lobster Pound where my parents reminisced about their prior visit some twenty years before by eating the largest lobsters they could find. My dad even somehow managed to come away with some vintage postcards from the time of their visit and a coastal New England restaurant guide all complements of Mr Markey who they chatted up as they are want to do. Woodstock and Burlington on the other hand, are worthy places to visit only if you have no other places worthy to visit.

Other highlights of the trip include my mom cleaning my apartment to a level of cleanliness it will likely never see again; my dad bumping, kicking, and karate chopping my coffee table sufficiently till one of the wooden rails broke off; and an early Christmas present consisting of a huge, new, flat screen television complete with swanky new stand which I am still not entirely sure what to make of. I think overall they had a pretty good time; I know for the most part I did. And I hope to eventually one day stop finding new bath towels in my cupboards, closets, and washing machine. Until then I gotta find a way to dispose of a dozen bagels and a half dozen apples before they go bad. Someone may be getting a pretty unique gift basket in the next few days here.