04 July 2009

There's more to it than hot dogs and explosives launched into the sky. Don't forget that.



IN CONGRESS, July 4, 1776.

The unanimous Declaration of the thirteen united States of America,

When in the Course of human events, it becomes necessary for one people to dissolve the political bands which have connected them with another, and to assume among the powers of the earth, the separate and equal station to which the Laws of Nature and of Nature's God entitle them, a decent respect to the opinions of mankind requires that they should declare the causes which impel them to the separation.


Happy Birthday, America. May freedom forever reign.

Inhale, Exhale.

Her name was Molly.*

Doing what I'm about to do is the direct result of something wholly terrible, yet I'm thankful for the chance to be here, because I can help right a wrong, after a fashion.

For now, though, I'm just breathing. No words come to my lips, no emotion on my face. I'm focused, singly, on a slow controlled inhale, and a slow, controlled exhale. My partner is next to me, and she knows me well enough to read the thoughts behind the look on my face. She's also experienced enough to know that right now, I don't want to talk, I don't want her to talk, and if anyone asks me "You doin' OK, JB?" I'm going to knock their teeth out. Her job, at this moment, is to just be here. That's why she's the best partner I've ever had as a medic.

Inhale. Exhale.

I glance at the door, beyond which sits a monster.

He doesn't look like a monster, of course. The real monsters never do. They look like normal folks. Some tall, some short. Full hair and balding. Square jaw, rounded face. Eyes set narrow to the sun, or thick Coke-bottle eyeglasses. "Just a regular man," you'd hear.

Except he was no man. He was a monster.

I don't want to look at him, yet as your eyes are drawn to a car wreck on the other side of the highway, mine will be drawn to his face. This guy is as regular as regular gets. He's a touch beyond 200 pounds, and tissue that was once muscle has turned soft, the result of too many beers and frozen dinners in front of a T.V. His head sets squarely on his shoulders, though if he had any decency, he'd hang it in shame. The shoulders are broad, and exude a relaxed confidence, as if he knows what's coming and knows he can weather the storm. A Timex on his right wrist -- he's a lefty, apparently -- marks time, and his back is straight. He's crossed his feet as he sits, relaxed.

Inhale, JB. Now exhale. Repeat.

Yeah, relaxed. After what this monster did, he's relaxing. He's relaxed, and I'm a mess of emotions: Anger, grief, curiosity, and perplexity.

And rage. Pure, untempered, primal rage. I want to face him with that rage. To ask him the questions that have burned into my soul since the first moment the dispatch said "Medic 9, Child injured, PD en route as well, RP states father of child is the suspect."

"You think you got enough salt to try that with me? Go ahead.... do to me what you did to her.

"Go ahead. Try to hold me down and force your fat, smelly, drunk-ass body on me, with your pencil dick and smelly breath. Try to touch me in spots that I don't want you to touch. Try it. Go ahead, try. I dare you. Nay, I BEG you to try that with me.

"She was 5 years old, and might have weighed 40 pounds. She called you Daddy. A daddy wouldn't have done this to his little girl. A father would have given his own life to prevent this from happening to his little girl. You're no daddy, you're no father. You're a piece of shit.

"I'm not that small, and I prefer a slightly different term for you than 'Daddy.' Go ahead... try that with me. Let's skip all the rest of this bullshit dog and pony show and get this over with. Don't bother looking at the cops, they won't help you. That, I promise. Let's do this... you, me, and last man breathing walks out of here a free man. Please. Try me."

That's what I want to say. That's what my face, my eyes, and my body language say. But it's not what my mouth says. I want to say it, but I don't. I just breathe.

Inhale. Exhale.

Having processed all these thoughts in the two seconds it took me to open the door and enter the room and glance at him, I remember that, despite my rage, despite my anger, despite my visceral desire to exact some revenge for Molly, am a professional and I have a professional duty to do my job. I take that first step to do what I have to do.

The cop reaches toward me, holding a book, and asks me:

"Do you solemnly swear that the testimony you will give to this court will be the truth, the whole truth, and nothing but the truth, so help you God?"

I give the monster one last glance: OK, pal, let's see you worm your way out of this one...You should have taken your chances with me, because Ordinary Decent Criminals in prison don't care much for child molesters. Have fun in there, and I hope you rot in hell.

"I do."







(*Name changed for the obvious reasons.)

I don't feel so wise anymore...

"Let's take 'em out."

Those four words, spoken as I sat in the dentist’s chair, would portend of things to come, though I wasn’t to fully understand just what those things would be until later.

The wisdom teeth weren’t fully “in,” and weren’t going to get any more “in” than they were now, and since two of them were half-impacted into the soft tissue, they all had to come out. That’s what the oral surgeon said, and he’s the doctor. I can hold my own in discussions about the emergency care of asthma, acute myocardial infarctions, anaphylaxis, or traumatic injury. But I don’t know squat-all about oral surgery, and this guy worked at Emory a while back, and we have some professional colleagues in common, and he’s a Brave’s fan, and he has a 1970 Camero with an LS6 engine and Tremec T56 transmission, so I reckon he knows what he’s talking about.

So the wisdom teeth were coming out. I’d talked my good pal Kim into giving me a ride, and she came through in classic Kim style: 10 minutes late. Since the surgery was slated at 7:30 am, I had to be there at 7:15. Calculating Kim time into the equation, factoring for morning traffic, and the distance involved, we left my house at 6:45. This, of course, meant getting up at 6:00 to walk and feed the dogs. However, the conscious sedation planned for the surgery meant that I was not to eat or drink anything after midnight.

I would like to submit for discussion that requiring someone to be awake at 6:00 am sans coffee should be punishable by firing squad.

I amble back to the room, where a friendly and cheerful (I bet SHE had a cup of coffee this morning!) nurse gets things started: Blood Pressure cuff (112/72) and ECG monitor (Normal Sinus, 62/minute, no ectopy, elevation, depression, or abnormality noted,) and Pulse Oximeter (98%, room air.) Somewhat amusingly, she offers me Nitrous Oxide to “help me relax” before the doctor comes in to start an IV.

Seriously? Nitrous before an IV? You’re telling me that after all those years of wiping off the dirt, making a quick swipe with an alcohol prep, and jamming in the 16g needle while bumping down the pothole laden streets of Atlanta in a 10 year old ambulance with no shock absorbers, that I was doing it wrong?

Hmpf.

I decline the Nitrous, explain that IVs don’t hurt and that I’m a man and can take it. She rolls her eyes in that “Oh, great… another testosterone fueled macho tough guy” way, and replies with an “Oh-kaaay.”

The doc walks in. He swabs the arm, sticks the vein, and mentions “I’ve got an advantage over you… I don’t have to do it while bouncing down the pothole laden streets of Atlanta in a 10 year old ambulance with no shock absorbers.”

The nurse says to me “What is it you do?” and I reply “Now, computer software, but I was a paramedic for more years than I can remember.” She gives me one of those “OK, you score one point for that” grins, and I reply with a wink. Let’s get this over with.

Ahhh…. Fentanyl and Versed: One of the classic combos of all time. Beer and hot wings. Chips and salsa. Laurel and Hardy. Fred and Ginger. Before long, I’m out of it. I vaguely recall the right lower extraction hurting more, and clenching the arm rest of the chair in a death grip with my left hand. I also recall the doctor asking me if I wanted to keep the wisdom teeth, to which I mumbled something that must have sounded like “No, thank you, Doctor,” and slowly coming around a short time later. Kim’s there, giggling at me and my drug-induced stupor, and the nurse is giving Kim some explicit directions about making sure I kept the gauze in place for at least two hours, took my pain pills, stuck to applesauce and pudding for the next couple days, and generally rested the rest of the day. With remarkable concentration, I managed to walk straight (more or less… more less than more more) to the car, and soon enough I’m home.

Post Op Day 1: I’m taking ibuprofen and Lortab as directed, start the antibiotics as directed, and have the great fortune to enjoy a Chateau Rothschild Rinse de Saline, 2009 Vintner’s Reserve. It has a lovely nose, a nice gritty texture with hints of bat urine and a turpentine base. Finishes with tones of formaldehyde and the itch of chewed sumac. Not too expensive, either.

Post Op Day 2: Pain is down, and I can get by with just the ibuprofen. Jaw feels like it met the fat end of a pool cue in a bar fight. Not that I’d know what that felt like or anything. I’ll save the remaining Lortab for another day, or perhaps put them in my backcountry medical kit, should I be out climbing and sprain an ankle or something. Getting pretty tired of pudding and applesauce, though. Sure could go for a more substantial meal… a nice bowl of chicken broth, perhaps.

Post Op Day 3: Dear God, I know I haven’t been to church since… well, a while. I’m sorry, really. I’d offer to go more often in the future, but it wouldn’t do to lie to the Almighty. So I’m only asking that you forgive me for this, and let me eat solid food. Just today, just once. Nothing much… a chicken wing. A roast beef sandwich with havarti, mayo, and lettuce. A boiled egg. A couple pounds of bacon. Anything, anything at all, just don’t make me eat applesauce and pudding again. Amen.

Post Op Day 4: The day starts as usual… coffee, salt water rinse, and pudding, with a side of applesauce. Follow up appointment today at 4:30, and the doctor says two wonderful things: The sockets are healing well, no signs of Dry Socket, and I can eat anything that my pain threshold can tolerate. That means some sushi and Crab Rangoon, and sweeter words have never been said since Becky Valentine told me I could hold her hand in 3^rd grade.

I’ve got another follow up next week, and expect things to be fine.

Now if I could just manage to eat a pizza.

A quick drive-by

I've been way too busy the past couple weeks to post much. Sorry about that, kinda, but there are things that have to take priority.

I'll try to do better. For now, no news is good news, OK?

Lastly, I had all 4 wisdom teeth removed today. Versed and Fentanyl really kick ass, I'll have you know.

At the moment, it's time to pop another Lortab and take a nap on the sofa.

Today

We started on a course that would change the world.

On Memorial Day

Remember the reason for the day.


This essay was written by Dr. John P. Pryor. He was a trauma surgeon who refused to be idle when so many wounded Americans and Iraqis could be helped by his skills. He enlisted in the Army reserve and wrote this article after completing his first tour in Iraq.

"In other fighting, one marine was killed in the Al Anbar providence after a humvee he was riding in hit an IED." That was what I read in the AP news piece. It was one line of several paragraphs that summed up the days casualties in Iraq during another day of the war that has gone on for three years now. These reports are so common, most people do not even read them, or listen to the 30 second blurb that follows, "Another day of violence in Iraq where..." on the evening news. For us, the reality is much different, a horrific drama that is played out in the field, in forward surgery tents, and combat support hospitals every single day.

Today the warning came over the radio, "urgent litter coming in by ground" I immediately respond to the ETR where the buzz is usually in full swing. "IED, Marines" is all the ETR nurse said as I walked in. Damn, I thought. One day left - all I asked God for was no more marines with one-day left on my tour. The hospital staff went into full swing - these people are at the end of a yearlong deployment here, they are experienced, hardened, and cool under pressure. The activity was programmed and efficient. I took my position at the head of bed number one, put my head down and waited.

Within a few minutes the litter team burst into the ETR with the first patient. I could see his arms dangling off the stretcher with bone exposed, and I immediately knew that this was going to be a bad one. When the litter was pulled up aside the bed, I saw the full extent of what I was up against. Driver, I thought to myself. The drivers always seem to get the full force of the IED. There is a pungent smell of
gasoline and burned flesh. My first order of business was to remove the IBA before we move him over; to do this we have to sit him up in order to pull the arms through the IBA sleeves. When we did, his arms, broken in several places on each side, flopped around like a puppet. As we moved him over, I tried to ignore the massive tissue destruction of his legs, and focus on potential life threatening chest and abdomen. He was moaning, actually a good sign, the brain was still getting blood flow. Anesthesia moved to intubate him, as the emergency medicine physician started the primary survey. Nurses started lines, lab was there to bring blood, medics held pressure on bleeding wounds, all in a dance that has been repeated so many times before.

The other patients began to file in, eventually filling the ETR. One soldier in a bed next to ours was calling out to my patient, ignoring his own gaping wounds "Your going be okay man, hang in there." I began to focus on the problem and my plan. Both legs had massive tissue destruction. The left thigh was torn apart and burned with a tourniquet at the groin. The right leg was mangled below the knee with a tourniquet
above that. There was a neck wound that wasn't bleeding and shrapnel to the face. Both arms had multiple levels of open fractures. The pulse was weak and the blood pressure was barely readable. We hung blood immediately. The chest x-ray did not show any thoracic injury. We shot an abdominal film to look for shrapnel that may have gone into the belly - none. As we moved to the OR the hospital commander stopped me to ask if he was going to make it. I told him that I was worried that once we start to resuscitate him, the bleeding would become even worse, and I didn't know if he would make it. His head dropped as he walked back to the chaos of the ETR.

In the operating room we started by getting control of the external bleeding of the legs. There was blood coming from everywhere; bright red arterial blood, dark blue venous blood, and areas where the two swirled together in pools between the flesh. Two orthopedic surgeons and I worked frantically to get control of the bleeding, which as predicted, became worse as we started to resuscitate him. Anesthesia was struggling to keep a blood pressure, infusing unit after unit of packed red blood
cells, and plasma. I was having trouble finding the source of some bleeding high on the thigh, and I was going deeper and deeper into the groin to track down the source. Suddenly my hand broke into a space, and a gush of blood came out. I realized that I was in the retroperitoneal space and the bleeding was coming from here. This was the worse case scenario. Bleeding from this location is the toughest area in the body to control. The packing did nothing; blood flowed from the wound in a constant stream. We opened the abdominal cavity and clamped the arteries that feed the pelvis, but it didn't help. Bleeding from this area is almost always from large veins that cannot be controlled with sutures or arterial control. We packed as tight as we could, and then put a sheet around the pelvis to pull the bones together in an attempt to tamponade the bleeding, but it was not enough. His heart went into a lethal arrhythmia. We shocked him, and pumped epinephrine into his blood stream. After a few minutes, his heart stopped for the last time.

The marine was dead.

There was an immediate silence in the operating room as soon as I announced the time of death. Most of the staff had tears running down their faces; this was a long year for them with so many of these kids dying in this room. I could not physically move for several minutes. I looked at this young kid, a child, and I apologized to him for not being skillful enough to save him. As a trauma surgeon every death I have is
painful, every one takes a little out of me. Loosing these kids here in Iraq rips a hole through my soul so large that it hard for me to continue breathing. After a few minutes, I collected myself and began to direct the care for his final journey home. We closed what we could of the wounds, and wrapped the ones we couldn't get together. We washed all of the dirt and oil off his skin, combed his hair and washed his face. He was transferred to a litter and brought to a private enclosed room where we placed him inside a heavy black body bag. The body was draped with the American flag and a guard was posted. The chaplain gathered some of the providers and we said prayers over the body.

There was, and always is, a palpable grief that comes over the entire staff when we loose an American solider. Everyone is affected, and everyone deals with it in a different way. For me, this is not an objective depressing thing to be a part of; it is very, very personal. I was the surgeon who couldn't save him. For me the grief is intolerable. I become the focus of the morning for the staff- people come and give me a hug. They ask me if I am okay, they pray for me. I appreciate it and hate it at the same time. Often my misery turns into anger. Sometimes I become angry with God for allowing this to happen. I just want the whole thing to be over, and all of these kids to go home to their families and live long lives. I have seen so many soldiers and marines die here; I just want it all to end.

As I made my way out of the hospital, I saw the marine unit gathered together. Two humvees where parked, and weapons were leaning against the vehicle. I notice this immediately because a marine is never without his weapon, they would never be stacked like that. These were the weapons of all the marines injured in the latest attack. I spoke with the first sergeant, the father figure of a marine unit. I know him well, we have lost several of his marines and had many more injured and treated here. We arrange for his buddies to come in and say goodbye, something that I cannot even bear to watch. After a time of reflection, the unit gathers the equipment and prepares to go out again that night. This is some of the raw courage that I talk about, the ability to loose a friend in battle and go right back into the fight. I love every single one of them.

The body was eventually taken to the LZ and loaded into a helicopter with some of his buddies as escorts. He is taken to BIAP where mortuary affairs prepared the body for transport home. A friend of mine was at BIAP when the body was loaded onto the C-130. All activity on the tarmac stops when the casket is brought onto the airstrip. All personnel in the area stop what they are doing and attend a 45-minute ceremony on the airstrip. They tell me that this happens twice to three times a day,
but everyone takes time out to attend the ceremonies. Soldiers manifested in these flights are going home or on R&R, and as anxious they are to leave, they all take the time to honor the marine. An honor guard then brings the flag draped casket onto the aircraft with full military honors. The casket is situated in the center of the aircraft with nothing placed on either side or directly in front or back. Personnel then enter the aircraft and accompany the marine to Kuwait. In Kuwait the casket is removed first, again with a full honor guard. The marine will be brought to Dover Air Force Base in Delaware, and then eventually home and to his final resting place.

If I could say something to this Marine's parents it would be this: I am so sorry that you have lost your son. We, above everyone else, know that he was a true American hero. I want you to know that the Marines, medics, doctors, nurses and of the 344th CSH did everything possible to save him. I want you to know that I personally did everything that I could, and that I am sorry that it wasn't enough. I want you to know that although we never knew your son, we loved him. I want you to know that although he lost his life, we preserved his dignity after death. We held his hand when he died and prayed for his soul and for God to give you strength. I want you to know that he had great friends who cared deeply for him and that they were also here when he died. He was never alone for his journey back to you. I also want you to know that I will never forget your son, and that I will pray for him and all of the children lost in this war.

IED - improvised explosive device

ETR - emergency treatment room

LZ - landing zone

BIAP - Baghdad international airport

IBA - individual body armor

R&R - rest and relaxation

CSH - combat support hospital


John P. Pryor, MD was a trauma surgeon at the hospital of the University of Pennsylvania and a Major in the United States Army Reserve Medical Corps. He was the general/trauma surgeon for the 344th Combat Support Hospital in Abu Ghraib, Iraq. John was killed on Christmas day 2008 during his second tour in Iraq.

Vick, the NFL, and Second Chances

"Does he deserve a second chance?"

Ultimately, that's the question that hangs over the head of NFL Commissioner Roger Goodell. Goodell has mentioned that he'll consider reinstating Vick only if Vick shows true remorse for his crimes, that he exhibits he has learned from his mistakes, and is willing to lead a better lifestyle befitting a man in such a high-profile role as NFL athlete.

I'm a dog guy. Anyone who knows me knows of my love of, and passion for, dogs. Through all of time, mankind has never created a bond with an animal quite the way we have with dogs.

In the world which we know, among the different and primitive geniuses that preside over the evolution of the several species, there exists not one, excepting that of the dog, that ever gave a thought to the presence of man. ~Maurice Maeterlinck

Dogs have served us in many role: On the battlefield, sniffing out landmines and other explosives; in the wilderness, tracking down missing people and escaped criminals; after a disaster, searching for victims buring in rubble; on the streets, guiding the blind; on the farm, herding cattle, sheep, and other livestock. They love without conditions, have courage without ferocity, serve without expectation of reward, and are loyal without question. They have virtues we wish we had.

Dogs have given us their absolute all. We are the center of their universe. We are the focus of their love and faith and trust. They serve us in return for scraps. It is without a doubt the best deal man has ever made. ~ Roger Caras

Being a dog guy, I find the concept of making a dog fight to be abhorrent. I find the idea of killing a dog because "It didn't fight well enough" to be more so. Would that we could apply the same logic to, say, NFL Quarterbacks: "Jeez, Michael, but you were only 10-28 today, for 117 yards, no TDs, and two picks. Best get right with Jesus, and be quick about it. Sorry, but that's how it is."

The dog is a gentleman; I hope to go to his heaven, not man's. ~Mark Twain

We won't do that, of course. A dog is just a dog, and there's thousands of them waiting in shelters, ready to be taken in. We also have a double standard regarding animals. Those who would be quick to condemn the idea of dog fighting have no hesitation biting into steak and eggs for breakfast, or a bacon cheeseburger for dinner. Killing a cow or pig is socially and morally acceptable. Killing a dog is not. Why?

(For the record, I like bacon cheeseburgers, steak and eggs, and chicken wings, so I'm as guilty of the hypocrisy as anyone else.)

Then there's that whole sanctity of human life thing we hold so dear in our country.

Yet our country also holds dear another principle: Redemption. Second chances. Making right by your past mistakes. Paying your debt to society and moving on in life. Becoming a better person.

My goal in life is to be as good of a person my dog already thinks I am. ~Author Unknown

It's possible that some folks won't ever get past this event. If Vick gets picked up by a team, they'll have to deal with PETA protesters at every game. There will be signs held aloft, shouts of "Dog Killer!" through a bullhorn, and so on and so forth. These protesters will punish the team for doing what is a basic American concept: Giving someone a second chance.

Does Vick deserve a second chance? I'd have to say he does, even if his crime was, in my mind, rather heinous. I can't deny him the chance to redeem himself, make it right, and learn from the error of his ways anymore than I could deny the same chance to anyone else. Vick had his chance with the legal system. He was sentenced to punishment by that legal system, and completed the requirements of that punishment as laid out by the legal system. He did what America requested of him. Now, America has to uphold it's end of the bargain, and let the man have a second chance. Commissioner Goodell has to uphold that promise as well.