Just The DFACs, Please

I have explained previously that our mess hall (officially here called the DFAC, or Dining FACility) is large, generally clean and well lit, and run by the Kellogg, Brown and Root corporation or KBR. In fact, we have at least four DFACs here on Al Asad, though only one large one—the rest are smaller operations, spread out across the post. I have only been to two DFACs at Al Asad, the large one officially designated “DFAC 3″ and nicknamed “Warrior Hall” and the smaller DFAC 1, which our unit calls “DFAC rat” because for a while, it was the only one which allowed any rations (”rats”) to be carried out of the facility. I actually prefer this smaller DFAC, as it tends to have better food, even though the selection is smaller. My counterpart in clinic, LTC Bullock-Price is almost fanatical in her allegiance to this smaller DFAC, and she has gotten to know the head cook, who confirms that he makes many of his own recipes and thus has some less-generic, not-quite-so-institutional foods there. I have discovered that if I go to the rat DFAC at night about 30 minutes before it closes, there will often be a large number of TCNs eating there, along with some very good ethnic foods which are a break from the hamburger-chili mac-spaghetti routines of the other cafeterias. I have had curry beef, semi-authentic asian stir-fry rice/noodles, jamaican-style chicken wings with a spicy pineapple sauce, and some Thai food at these late hours. Problem is, I don’t always want to eat at 7:30 PM.

Weather (or Not)

I will spare you yet another description of the dust storm which seems to be an ongoing phenomenon this week; I think I have beat the dust thing to death, and then some (though it has also beat me to submission). One thing I really miss here is the ability to have some idea ahead of time what the weather will be like. There are no forecasters here, and if there were, they probably would not give the info out to anyone lacking a top secret clearance. There is a site, weather underground, which purports to give a forecast, but it appears to rely on its patrons to report conditions, and the forecasts seem to be even less grounded in reality than your local news forecast. So we live without much foreknowledge here. Every day, I open the door of my canister while still in my undies and peek out into the world at large, to see what kind of day it appears to be. There are three possibilities: 1) hot, 2) dusty, 3) hot and dusty. There is a theoretical fourth option (rainy), but other than my first night here, this has been a theory without much merit.

Mailbag

No mail again yesterday, but there a rumors that today may be a “go.” UPDATE: No soup for me. Bummer!

That Space Cadet Glow

For those who do not know, I had LASIK surgery in 2003, and I had a complication called diffuse lamellar keratosis, which resulted in poor and constantly fluctuating vision for months, the need for a second, reparative surgery, and, eventually, the loss via inflammation of most of my tear glands. Hence on a daily basis, I deal with dry eyes, which is a lot more bothersome than it sounds. Severe dry eye syndrome leads to chronic scratching of the cornea, which causes pain and can diminish visual acuity. LASIK is described by some advertisers as a “miracle” surgery with few-to-no side effects, but I wouldn’t personally describe it that way. Nor would the many community members at dryeyezone.com, where I often lurk and occasionally post. The tips I have learned from members of that online community have greatly improved my situation, which was pretty terrible for a couple of years. Recently, the FDA has revisited the “labeling” for LASIK surgery, and in a forum last week, they got an earful from post-LASIK patients, who have come out en masse to describe their sometimes horrifically tragic stories. As a result, the warnings regarding LASIK surgery are likely to be made larger and stronger.

You can imagine that Iraq is not a particularly fun place to be for patients with dry eyes. I have personally survived with the great help of frequent eyedrops, careful ocular hygiene, and (mostly) my wonderful $450 Panoptyx wrap-around goggles, which keep all of the wind and the dust away from my eyes when I wear them. None of my bike rides would have been possible without those babies, which have served me incredibly well for nearly 5 years now. I don’t wear them all of the time, because they have a rather uncomplimentary “spaceman” look about them, but outdoors here, people cover their eyes with all sorts of funny/ugly things, and so people are used to the space-cadet appearance.

Gonna be a quick one tonight. Due to the cloud o’ brown, we have had no mail flights in for the past 4 days, so if you sent me a package and I haven’t sent you a thank you, it is probably because I haven’t yet received it.

I wanted to point out that the term “TCN” (which I used in my prior post to refer to the native working here on post) is not a derogatory term, nor is it a nickname. In the military, acronyms and just plain spelled-out first letters are often used to denote people, places and things. For example I am the medical OIC of our clinic (officer in charge). CPT Allen is my CO (commanding officer). President Bush is our CINC (commander-in-chief). When I re-read yesterday’s message, I thought I might have sound dismissive of the locals and third-country-nationals, if you did not know that in the military, acronyms are just part of the milieu.

A further word on the “local” people. One of my friends from many years ago is a man who has spent much time with Arabs in the middle-east, and at the beginning of my deployment, he wrote me, saying that “Arabs are the most hospitable people in the world, and the most implacable enemies.” I am grateful that I have, as yet, only seen the former aspect. When we take care of foreign nationals, they are incredibly grateful, including those who are clearly making much more money than any of us. It is amazing how much of a difference a little prilosec makes in the life of a man who has had 30 years of stomach pain. Almost all of the TCNs, and especially the Turkish, Lebanese, Iraqi, Kuwaitis—these folks just about always bring back something after we have treated them. A couple of days ago, it was Turkish bread, cooked right on post here in a stone oven, with some spices on top. Delicious.

Today, one of the crews we’ve taken care of brought us a bunch of office chairs with wheels. The chairs are slightly used, but beautiful nonetheless, as we have been sitting on folding chairs since I got here. (Most of us had a pillow on our chairs to make the ride a bit softer, but after a few weeks, no one wants to touch one of those sacrificed pillows.) One of the chairs had a message to one of our medics written across the back in permanent marker, to make sure everyone knew who had earned that gift. Just a little thing which makes our lives a bit better, and I suspect that the chairs were a substantial sacrifice for the men who gave them up.

From the “Have I Mentioned The Dust?” department: Yesterday we got absolutely walloped with the biggest sandstorm yet, right at mid-day.

The air was clean when I had run to the clinic at about 9 AM to print out my lesson for church. On my way back, however, I was cursing myself for not having brought my wrap-around goggles with me, as the wind was picking up, blowing a bit of dust in my face. I rode home with literally one eye partly open, looking up only when absolutely necessary. I did not think to look northward, for an impending duster, but it must have been there. When I made it back to the canister, I sat down to read and write, and after ten minutes or so, I noticed a rapid change in the light level coming through the window. I got up and spread the venetians just enough to peek out, and everything had a bright orange hue to it, the result of the dazzling midday middle east sun shining through the aerosolized brown dirt. I grabbed my specs and my camera and walked outside into the lysergic landscape. I literally could not see ten feet in front of me.

Back in the canister a few minutes later, I turned off the A/C, hoping that would keep the inside dust levels down, but no dice. I could taste the chalky stuff in the air, and realized that my PlaySkool house must be a bit less hermetically sealed than I had thought. As an experiment, I turned off all of the lights, and pointed my LED flashlight into the nothingness. There was an amazing amount of dust swirling in the air, especially for a room in which there was no discernible air flow. Within 20 minutes, a layer of orange grit had covered every exposed thing in the room.

I had reserved the clinic truck, and was grateful when it was delivered to me at 12:30, which meant that I would not have to walk or bike to church. The turnout for the meeting was low, as expected, but not zero as I had feared. All told, there were five of us initially and one joined later. I was glad I had the truck, so that I could give people a ride back home. Between myself and the Serviceman’s Group Leader, we got everyone in a car except the chaplain, LCDR Vance, who wanted to walk.

The aftermath this morning was quite impressive, with a nice layer of orange-brown on and in everything. I woke up feeling like I couldn’t breathe in all the way, which was a momentarily scary feeling, but by the time I was up and around, and had coughed out some huge brown gobs (sorry!), I felt much better. The air had cleared up a bit, but it never got quite back to normal. In clinic, we had quite a few coughers and respiratory complaints from people who must have sucked in the same pounds of dust that I could feel heavy in my own airways.

We joke around here that, by the time the Americans pull out of Al Asad, “orange lung disease” will be a well-recognized entity.

——————

By popular demand, I have a case for you tonight. Will try to get more of these out there, maybe one a night for a while.

Today, a “TCN” came in with half of his finger missing. “Third Country National” is a designation throughout the war zone for the people who are not Americans (or part of the multi-national force), nor are they Iraqis. They are from various countries ranging from Sri Lanka to Cambodia to Pakistan, India, Saudi, Kuwait, Qatar, Turkey, and even as far West as Uganda. These usually very humble people have jobs ranging from construction, to flippers at the post Burger King stand (this is NOT your dad’s B.K.), to checkers at the PX.

For reasons that are not at all clear to me, people of certain nationalities seem to have a “lock” on certain jobs. For instance, the Ugandans have somehow gotten all of the security detail for Iraqi bases, so that every time I pass a check point, I am greeted by a thin, very dark-skinned black man, with a massive white toothy grin and a pleasing, almost Caribbean-sounding accent. These men are animated and friendly, and always seem genuinely happy to see me, even though they don’t know me at all, and must have hundreds pass by them daily. They respond with great warmth to any attempt to speak their Luganda language, so we always offer them a heartfelt “zhum-bo” (begins with the same sound as in Zsa Zsa Gabor’s name, and ends with a firm accent on the last syllable). They always, always respond to this with a hearty “zhum-bo” and often all of the men in the checkpoint house will come out to greet the traveler. They are not averse to shooting people who attempt to proceed without having been properly vetted, though, and have in a couple of known cases, stopped bad guys from getting onto our bases, often with force.

Back to the story. This TCN who is a Turkish contractor, had the top of his right index finger completely degloved after having a cement block fall onto the digit while he attempted to get it out of the way. Sounds a bit suspicious, and I suspect that some gears or other mechanical device had something to do with his predicament, but the above was the best I could make of his story, as there was quite a language barrier, and he was in a lot of pain. The bone was sticking out of the avulsed top of the finger, but the meat had not been cleanly peeled off, and the little artery at the top of the finger was exposed, which made quite a bloody hamburger mess. Because nothing appeared to be broken, we simply cleaned the wound (without any sedation or narcotics, poor guy) dressed it, gave the poor guy an Rx for some percocet, and sent him up to the CSH to get his drugs and some x-rays (reportedly negative). He’ll be back every day or so for a dressing change until he has scab over the entire wound. May need some antibiotics along the line, as I suspect he will continue to work, despite our recommendations to the contrary.

I don’t know for sure, but I suspect that there are no unions looking out for the TCNs, nor workmen’s comp, nor even one of those signs up that says “12 days without an accident.” But every one of these workers seems pretty happy to be here, all the same. How do I feel about being here? Glad to have a good job, one I will like a whole lot better about 125 days from now.

At about 2100 hours, I get out of the shower, put on my Army PT shorts, and with a brown towel hanging around my neck I begin to walk the 100 or so steps back to my room. I use the little LED light on my keychain to guide me back towards my canister. After walking a dozen steps away from the latrine, I stop for a minute, just to take things in. I am in Iraq, I remind myself. This is, reportedly, an actual combat zone, and the cradle of humanity. Every few days here, I force myself to stop and to breathe, and to experience this experience. I flip off the flashlight.

It is dark where I am, but there are a few ambient light sources which allow some observation once my eyes adjust. The surround sound of Al Asad fills my freshly-cleaned ears with the seemingly endless noises of industry. Back and to the left of me is the sound of a tractor, likely coming from the garishly-lit maintenance area north of our camp. I wonder why a tractor is operating at 9 PM. Whatever its reason, that same tractor is always busy at this time of night, every night. Twenty paces in front of me, some chatter: a group of very young-looking men and women are standing in a circle, all in the same grey t-shirt, some of them smoking. Occasionally, a burst of laughter punctuates the conversation. I cannot make out many of the words, but one particularly sharp word seems to slice through the night air to me every 15 second or so. Farther ahead are the sounds of cars, trucks, and buses moving along the road behind the concrete barriers which surround our cans. From above me comes the crescendo-decrescendo of planes, mixed with the occasional helicopter or osprey. One aircraft has green lights on its propellers, which results in a neat laser show in the sky a few hundred feet above my head.

The air is hot (more that 100 degrees still), but pleasant anyway. A light breeze seems to do nothing to cool it down, and the balminess feels exotic and luxurious. I imagine myself on a tropical island in the 1950s a la Bob Hope and Bing Crosby, or else dropped into the watercolor universe of a Donald Fagen song:

The surf was easy on the day I came to stay

In that quiet island in the bay

I remember the line of women all in white

The laughter and the steel bands at night

But the smells around me are not of the sea or the sand. Instead I am greeted with the familiar refrain of dust and diesel, this time mingled with cigarettes and a faint smell of burning plastic.

I start on my way again, and walk by the group-in-grey. These are a few of my medics: a tall blonde kid from Minnesota who has a wholly-feigned world-weary look; a stocky Hispanic kid whose young appearance belies his wife-and-two-kids responsibleness; a dark-haired, dark-eyed girl who looks younger than Maddy; a heavily-tattooed, musclebound white guy who is at present time dominating the conversation with a story which sounds likely to be “topping” a previous one. They stand up a bit straighter when I walk by, and offer a genuine “hello, sir” but I choose to mosey along, and enough steps away from the circle so that my exposed white belly goes unobserved. I offer a heartfelt “goodnight” to them, and wave over my shoulder without looking back. Not the time for a conversation. I make my way back to the trailer.

————–

Earlier today, I rode my bike around the big loop which completely circumnavigates the Al Asad airport, or “flight line,” as it is called. The wind blew me mercilessly during the back portion of the ride, so I was slowed to a crawl for about seven miles. Because of this, I ran out of water, which I keep in a special “Camelbak” canteen, which wraps around my torso and hangs off of my back, its two-foot rubber tube allowing me to drink as I ride. Pretty nifty device, but it works much better when there is water in the bladder, which holds three liters. I had about six miles to go when my supply ran out, and the large depositories of water bottles which are so commonplace in the “city” are nowhere to be found out here amid the nothingness.

I had some concern about the lack of water in the 110-degree heat, but I knew that I could make it back to camp safely, as I felt very well-hydrated at the time I took the last sip. Further up the road, I came across a pallet of unopened bottles which had likely fallen off of a truck. The bottles were sealed, and I knew they had to be relatively “fresh,” as they were not there on my prior bike ride three days ago. But I did not partake. Part of me did not want to pour that 110-degree water into my Camelbak and drink. Part of me was simply afraid to touch these things on the side of the road. Here in Iraq, we tend not to touch anything which has not been proven perfectly safe, preferably by a instrument, rather than a person. I once came around a curve in the road and saw a mattress lying there, smack in the middle of the asphalt. I rode over towards it, thinking to push it to the side of the road, so that some unfortunate person in a speeding vehicle would not encounter it. But I had second thoughts; I don’t want to be remembered as the foolhardy doctor who managed to find the only IED on the entire base. So I left it there, and rode a wide circumference around it.

I decided against the “gift” water and rode on, past a one-room, abandoned brick building of a sort seen often on this post. As I passed this one, though, I noticed something moving around it, and then the thing noticed me. It was a small, red, dog-like animal with clean, abundant hair like a Husky. I would have guessed it was a fox, but I’m not sure that those exist out here, and my internet connection at present won’t let me google to find out. Whatever it was, it had buddies. They were convinced that I was about to lay claim to their fancy brick den and after conferring for a moment, they were now abandoning ship. I stopped my bike and watched the group scatter towards and eventually under the barbed-wire fence. I watched for a while as they scattered, hoping that none of them would find an IED.

There aren’t too many people who regularly venture out past the airport, at the limits of where they allow us to exercise. It is a long way from home, and I imagine that a flat tire would make for a long and miserable trip back to the city. But it is strangely spiritual in the desert. When the dust level is low, I can look out over the barbed wire, into the vast “buffer zone” which surrounds this base, and the land looks starkly beautiful, and immensely large. There are a few brown bushes, and some red-orange hills and plateaus, but mostly there is just land, as far as the eye can see. I remember as a kid riding to grandpa’s house in Kansas, past seemingly endless fields of corn and wheat. The feel of that place was similar to this (except greener).

There is a Joe Jackson album (”Big World”) which has about 20 songs built around a concept: although the singer has been “everywhere” and his world seems to be shrinking, he has these occasional, brief moments of stunning realization of the greatness of it all. These moments come as he sees vast expanse, or utterly unique sights:

Strange how the world got so small

I turned around, and there was nowhere left to go

So sad, the dream almost died

Each new arrival closes places in my mind

 

But I will dream

Before I go

Of smells that I don’t recognize

 

But by the river in Shanghai

The color of the sky

Is something I’ve never seen

After the summer rain

Children smile

Curious and kind

And the world is big again

Sorry guys and gals, long day today, and I did not have much computer access, due to circumstances beyond my control. I will get a longer message out tomorrow, including, by popular demand, some interesting medical cases. Had a few this week, including another pregnancy, a patient with herpes of the eye (not a laughing matter, and not sexually transmitted—truly a sad case, but I have high hopes for the soldier), some spider bites, an ulcer, and some others.

File under “It gets hot in the desert”: 118 degrees today at 2 PM. Tomorrow is supposed to be warmer, and next week, the high 120s.

Quote Of The Day

The Democrats are the party that says government will make you smarter, taller, richer, and remove the crabgrass on your lawn. The Republicans are the party that says government doesn’t work and then they get elected and prove it.

 

PJ O’Rourke

See you tomorrow!

On my way to Al Asad, I had a few “layover” days in Kuwait. There, I spent an inordinate amount of time in a tent, ducking the sand and the heat. My roommates included a few other medical types, among them COL Robert Vigersky whom I had known from my days at Walter Reed Army Medical Center (WRAMC). One day, as we were reminiscing about life in the DC area, it occurred to both of us that we had simultaneously come full-circle: we were both at WRAMC on 9/11, and now here we were on the Middle East on the five-year anniversary of the commencement of Operation Iraqi Freedom.

September 11 has always been a special day for members of the Rupard family, as it marks the birthday of one Rebecca Ann Rupard (who later became Rebecca Ann Anundson). Becky is the girl of a thousand nicknames: she was a tiny little thing as an elementary school kid, and so her nickname became “Speck-y” which evolved into just plain “Speck.” For much of her teen years, she was (for reasons unclear to me) “Beckles” and eventually “Beckles the Clown.” In fact, I’m pretty sure that there was a time when just pain old “clown” sufficed. Everyone loved Becky, and we all love her still. She possesses the enviable characteristic of being a truly happy person—not in some cheesy, depression-masking sort of way, and not in the way that a drooling chocolate labrador is “happy” as he licks your face. Becky is genuinely glad to be alive, and has been in all of the days that I have known her. One of my colleagues here recently described a particular medic, admiringly, as someone who “cannot be broken.” That is Beckles the Clown to a tee, and that is one of the many reasons why we all love her.

Unfortunately, Becky’s birthday was befouled by the terrible events and evil deeds of 9/11/2001, which has now become for all of the Rupards the birthday that will live in infamy. 9/11 is also notable for me, as my birthday is just two days later, on the 13th. This initially fortunate proximity resulted in no relatives forgetting either of our birthdays the way that big brother Barry’s is occasionally overlooked, being way out there in May all by itself. Now, though, Becky’s special day is remembered by nationwide half-masts and moments of silence.

On September 11th, 2001, at the time the first plane hit (around 8:45 AM), I was in morning report at Walter Reed Army Medical Center. In most Internal Medicine residencies, one of the graduating third-year residents is chosen to stick around for a fourth year, during which he is dubbed the “Chief of Medical Residents” or Chief Resident for short. This is a staff position in most hospitals (meaning that the Chief is considered, on paper at least, to be a full-fledged faculty member). The duties of the Chief Resident at WRAMC are many and varied, ranging from the planning of the schedules of every non-surgical intern, to the administration, teaching, and general herding of the Internal Medicine residents. For the academic year 2001 to 2002, I was the Chief of Medical Residents at WRAMC.

Being Chief is a fun job, but a challenging one, especially at an institution like Walter Reed, where every resident is brilliantly smart, and many are inevitably smarter, on some or all subjects, than I. On that sunny morning, we were reviewing cases in morning report, and when the meeting let out, I remained behind to speak with one of my colleagues in the hallway. Sometime around 9:05, a medical student came up to us and explained that a plane had just hit one of the World Trade Center buildings. I nodded “okay” to him, and continued my conversation, not thinking much about it. A few minutes later, as I walked the long cement hallway back to my office, I heard about the second plane. I can’t remember exactly who told me that bit of news, but I recall that we both wondered aloud whether terrorists were somehow involved.

I walked briskly down to the second floor, to the office of my direct supervisor, LTC Gregory Argyros. LTC Argyros had a television in his office, ostensibly for teaching purposes, but I had never seen it turned on until that moment. The picture on the screen was of the Pentagon, with smoke billowing out of one of its sides.

“What happened?”

“They don’t really know” he offered very calmly and deliberately, like always. I had seen Greg in normal moments, as well as in moments of anger and crisis (i.e., a suddenly arrhythmic patient), and he always had this same calm demeanor: everything was workable, all crises could and would be handled. Exactly as he was at that moment. “They think a bomb may have gone off inside the Pentagon.”

“What would you like me to do?”

“The hospital command is going to meet in a few minutes, and we’ll make an emergency response plan. I think it will require every set of hands that we can find. Call all of the residents into the hospital.”

“Including the doctors who are post-call?” I asked.

He thought for a few seconds. “Yeah, I think everyone should come in.”

I walked back to the elevator, mentally making a plan for mobilizing all of our people. When I stepped back onto the seventh floor, I walked past the morning report room, and noted a group of people standing at the large windows, looking towards the southeast. It took me a minute to see what they were seeing, but then became clear: a stream of smoke was floating up into the sky, from somewhere far behind the parking garage. It looked blackand noxious and evil, and it looked much, much too close to myself, my work, my patients, my home, and my family.