Getting a late start on the blog tonight. I will finish up my description of our clinic’s organization and personnel this weekend.

Today has been somewhat eventful. Fridays are long days for me, as I get up early and head to the gym for an hour. When I got back to my can, I hopped in and out of the shower quickly and then made my way to breakfast.

Breakfast is truly the best meal here on Al Asad, as just about everything they serve at present time is fresh and (most importantly) real. This was not always the case; for the first two months I was here, the eggs were always powdered-scrambled. Now, for more than a month, we have had real bona fide eggs, which has resulted in my making it out to breakfast more often. Today, I had a great omelet, with some green peppers, sausage, mushrooms, and cheese, and I managed to smuggle a few bowls of raisin bran (in convenient, sealed, one-serving containers) out of the DFAC for lunch, and a snack over the weekend, along a couple of cartons of the irradiated milk (Parmalat-style, in the square boxes, but with Arabic writing) which is all the rage around this place.

Back in the clinic, I had a few minutes before opening bell, so I sat down and started to pull up my Wall Street Journal articles on the web. It takes 15 minutes to open a single web page, so I look at the editorial page content and click like a madman, opening all the tabs I want, and in an hour or so, I’ve got some good reading material. I love Fridays, because there is usually a new Peggy Noonan piece. No sooner had I started this process, when the internet went down. In a few minutes, we learned that our little town had gone into “River City” mode again (the term used here to let us know that one or more of our own has been killed, and that family has not yet been contacted).

As you can imagine, this puts a pall on things; pretty much every soldier, sailor and marine on this post has made it through our doors at some point, and it is very very sad to know that the altar of freedom has required yet another sacrifice. As if in response, the weather turned unexpectedly dour—distinctly unusual for Iraq in the late Spring/Summer months, when cloudless skies are usually clockwork. Today, there were thick, unusual-appearing banks of clouds, and we even had a few flashes of rain through late afternoon. Then things cleared up almost instantaneously, and it was like somebody switched the heat on full blast; by four PM, it got up to 110 degrees (from high 80s in mid-morning). We had a volleyball game planned (we generally have some kind of get-together on Friday nights), and almost talked ourselves out of it because of the heat, but eventually seven of us traipsed on down to the Gym to play. An eighth was supposed to meet us there, but never showed, and a young Jordanian kid jumped in after watching our lopsided teams play for a bit. He did not speak English much, but was a pretty good player, and having him there kind of kept all of us on our best behavior, which was nice.

As we played, we could see a cloud of dust slowly descending upon us from the south. At one point a massive quantity of gnats ran right through us, apparently attempting to stay one step ahead of the mountain of airborne sand off in the distance. As the sand cloud came closer, hundreds of bats filled the air above our heads, again likely escaping the impending dust storm. Creepy, but kind of neat to watch. Eventually, we decided that we are at least as smart as bats and gnats (okay, at least the gnats), and so we took off for home as well, and made it just before the darkness descended.

Many e-mailers and a few commenters have asked me about the people with whom I work in the clinic. I thought I’d take the time over the next two nights to explain a bit about how our clinic is organized; I think our staff “layout” is likely similar to those in other large Troop Medical Clinics in Iraq. I will discuss some necessary preliminaries tonight, and will discuss our clinic specifically in tomorrow’s post.

First, to offer some perspective: On Al Asad, there are at least six places to which a sick person can go and be seen by an bona fide physician (MD or DO). This rather large number of facilities surprised me when I got here; I had presumed that Al Asad had two clinics and that we were the smaller clinic, and the Combat Surgical Hospital (or CSH, pronounced “cash”) was the larger one. But I did not know how very many soldiers/sailors/airmen/marines we have here. I can’t give you that number here, for security purposes, but suffice it to say that we are a good-sized community. Like the CSH, our Troop Medical Clinic is also a big fish in this pond; we have a fixed facility with an MD, a PA, ten medics, one pharmacist, and one soldier who doubles as our lab technician and our medical records clerk. To be clear, the CSH is much larger in terms of staff (around a dozen doctors, at least that many nurses, an entirely staffed lab, pharmacy, operating room, emergency room—essentially all the things you would expect in a small community hospital). However, by all accounts (from my friends who work at the CSH), we are considerably busier than them, at least on a per-provider basis.

Probably busier still, however, are the “one-doc-shops” sprinkled throughout Al Asad. I don’t know where all of these are located (I think that is by design—there is a certain amount of “mandatory ignorance” in all things military during wartime), but they likely represent one- or two-room facilities in larger buildings. I think of a time many years ago, when I was a student at the Uniformed Services University of the Health Sciences, and was lucky enough to have been randomly assigned to the White House for my “Introduction to Clinical Medicine” class. We met with the White House physicians at that time (Drs. Cavanaugh, Mariano, and Elting) in a small “clinic” on the first floor. I suspect that some of the Marine and Navy units here have similar set-ups, so that they do not have to travel too far to get seen. Also, there is a tendency for members of the Navy to trust Navy doctors more than Army, and vice versa. This is silly, but I have found it to be the case quite often, outside of the medical centers where everyone works together.

So we see mostly Army personnel, with a lesser quantity of Navy and Marine servicemembers, and just a few Air Force. We also see DoD civilians and TCNs, as I have mentioned previously in the blog. I have an additional duty, as I have been designated (by nothing more than happenstance) as the Hematology consultant for the OIF theater of operations, and thus I have seen about one patient a week as a blood specialist; these specialty patients come in all uniforms.

The bottom line to all of the above is that there are multiple medical facilities here on Al Asad; we appear to be the second largest of these in terms of patients.

Now, before I get into how our clinic is set up, allow me to digress for a moment to discuss Army ranks, with some commentary.

ENLISTED
E1 (Private, PV1) – Our clinic has none of these. This is the lowest rank, reserved for those who are still in basic training. The lowest of the low.
E2 (Private, PV2) – Again, none of these, and they are rarely seen in theater. These kids are usually a bit too green for deployment; the only one I’ve seen here was a PFC who was busted down a rank for misbehavior. Soldiers who stay here too long after completing basic training, do not end up remaining in the Army for long.
E3 (Private First Class, PFC) – Again, we have none in our clinic, though most units here have a few. These are usually young guys who are moving up in the world, but still have a ways to go.
E4 (Specialist, SPC) – Soldiers of this rank are everywhere; probably the most populous rank in theater. Of my ten medics, we have six E4s, two E5s, one E6 and one E7. In some cases, E4s are in a position of authority over other E4s and lower ranks, and are called Corporals.
E5 (Sergeant, SGT) – Soldiers who rate E5 or higher are referred to as “non-commissioned officers” (NCOs). This is less of a “worker bee” position, and a bit more into the leadership and admin stuff. The great majority of E1-3 make it to specialist, but less than half of SPCs ever make it to SGT. These soldiers are expected to be top-notch, and to be an example to their fellow soldiers.
E6 (Staff Sergeant, SSG) – A sergeant with a bit more authority.
E7 (Sergeant First Class, SFC) – Yet more authority. Takes many years as an NCO to reach this level.
E8 and E9 get tricky, as there are multiple levels of each, with names like 1st Sergeant, Master Sergeant, Sergeant Major and so forth. Suffice it to say that even most careerists do not attain these ranks, and that these soldiers are generally cream of the crop, hard workers, and respected by their inferiors. We do not have any of these in our clinic.

OFFICERS
O1 (2nd Lieutenant, 2LT) – What I was for four years as a medical student; again, the lowest of the low. Though 2LTs outrank the higher enlisted personnel on paper, the reality is quite different. Those who do not show the proper respect to NCOs will severely limit their military careers.
O2 (1st Lieutenant, 1LT) – Usually an automatic upgrade after a year or two as a 2LT in the regular Army; in the Medical Corps, we skip this rank when we graduate, and become O3s. Low-ranking officers are (fairly or unfairly) not always respected a ton by the rest of the Army: higher officers see them as peons, and enlisted personnel see them as “greenies” with little practical Army experience.
O3 (Captain, CPT) - What I became on graduation. For most people, this is a six-year rank or longer. Again, precious little respect.
O4 (Major, MAJ) – As with E5, this is where the weeding-out starts to occur. Most lower officers do not survive this far, for various reasons. Majors get a decent amount of respect, as theye have generally been around for a while. In the Medical Corps, however, this is an “automatic” promotion as long as the doctor does not have a big black mark on his/her record (i.e., can’t pass the physical fitness test).
O5 (Lieutenant Colonel, LTC) – Getting up there. More respect, and most of these on-post get a “wet trailer,” i.e., a shower and toilet in their can. Not too shabby.
O6 (Colonel, COL, “full bird”) - Really hard to get here, though less so in the Medical Corps. This is a position of a great deal of authority, and these folks have generally earned the respect which they get from everyone.
O7 through O-10 (Generals of various types) – A tiny percentage of officers make it here, and practically no medical corps people. At Walter Reed, I saw Generals in the hallways every day, but since I left that place, sightings are relatively few and far between.

[To be continued...]

First things first: I have good news, and I have bad news.

THE GOOD: The hermit crab is currently sitting in a glass container on my desk. I sweet-talked the soldier into giving him up (at least temporarily) and with help from alert blog contributor and Biologist, Dr. Steve Jordan, we may attempt to identify the creature more specifically, on the way to making this unique case a medical journal submission.

THE BAD: The aforementioned glass container is a test tube (actually a blood draw tube, but essentially the same thing). It seems the teeny tiny little dude bit the dust (perhaps literally; this is Iraq we’re talking about), as there was zero activity from him all day. Like all crabs, hermits need water to breathe, and I’m guessing that the humidity in the auditory canal kept him alive, but that outside of his little happy place, he dried out quickly.

Still, his krabby legend lives on, and we’ll see if we can memorialize him by publishing his sad tale.

————

The weather cooled off nicely today, which made for a nice break from the past week. I got an ACU uniform in the mail, one which I had ordered from the “Kyloc” system which alows deployed soldiers to get replacement items up to around $50 – $100 per month while we are here. I needed a third uniform just to make the laundry cycle a bit easier. With three Unis, I can have one at the cleaners, one hanging in my closet, and one on my person; then, if I get blood or something yucky on the uniform I’m wearing, I’ll have a fresh one available. This hasn’t happened often, but it did happen once (yucky, not blood). Also, as with all pieces of Army apparel, the uniforms are made by different companies, in different countries. The ACUs issued to me at CRC were of a strange, much wrinklier material than the ones the medics here have. An inspection of the tags showed that mine were made by a different company. The new one I got via Kyloc is the stiffer, more “pressed”-appearing type which is much more common here. So now I’ll fit in with the other kids!

————

As I write this, I can hear my buddies just outside my door, watching the new Indiana Jones movie on CPT Baker’s massive laptop. How do we have Indy, you ask? Well, the answer to that, my friend, is one of the best-kept secrets of deployment. Turns out that they often make current movies available freely to deployed military personnel. Of course, I should stipulate that by “they,” I am not referring to Warner Bros or Paramount. I am referring to French bootleggers who went to the movies with a digicam in tow, and “filmed the film,” so to speak, then made it freely available to us via the internet. (Just doing their part for the war effort…)

This illegitimate copy then makes its way to a big hard drive which certain computers on post can access, and can be downloaded from there to a thumb drive. These tend to be of questionable quality, and one can occasionally see someone with a big tub of popcorn make their way across the screen; also, they often have that annoying feature where the audio gets more and more out-of-sync with the video as the movie plays. But the soldiers watch them anyway. And then they watch them when they show up (again, free, but legit this time) in the theater on-post in a month or so.

If it sounds like the soldiers are getting a free ride here, I’d suggest to you that the cost of this gratis entertainment is likely recouped by Hollywood on military sales of the movie “Gladiator” alone. Every soldier in Al Asad (man, woman, hermaphrodite) has that DVD, everyone loves it deeply, and everyone is amazed, shocked, appalled and sometimes even angry when they find out that I have never seen the film (and, no, I don’t wish to see the seven-hour director’s cut tonight, thanks anyway). I narrowly escaped yet another “Gladiator” showing last night, and overheard talk of an “all-Roman-warriors” theme to this week’s Centurion Can City film festival. Doesn’t sound so great to me. Think I may just stay snug in my shell for the next few nights.

On Saturdays, we have a half-day clinic in the AM, and I am the lone licensed provider, so I see all of the patients. This allows my colleague, CPT Hall, to get a day off, and in turn allows me to take Sunday off. Not a bad deal.

We had a very strange bunch of patients come in today; it was like bizarro world. Usually we see a roughly equal amount of stuffy noses, gastrointestinal illnesses, and back/ankle pain. Today, I had few of the routine folks and a whole lot of the “fun” (or at least “interesting”) cases.

One was a young marine, with a northeastern accent. His first words to me when I walked into the room and asked him what brought him in today: “I learned that what happens in Vegas doesn’t always stay in Vegas.” And indeed, for this unfortunate young man, it did not stay in Vegas. Turns out he had spent time in a casino bar and “picked up” a girl there, and had unprotected relations with her. For the purposes of knowing what kind of things this stupid kid might have exposed himself to, I needed some more info on his sexual partner.

Me: Was this girl a prostitute?

Marine: No, she was just a girl in the bar.

Me: Did she work in the bar?

Marine: I think so, yes, sort of.

Me: Sort of?

Marine: Well, she didn’t get paid by the bar. She got paid by the customers in the bar when she did things for them. But she only “hung out” with me because she liked me.

Me: Did you pay her to “hang out” with you?

Marine: Well, yeah, but she wouldn’t have taken the money from me if she didn’t like me. So she was just a girl in a bar who sometimes got paid to “hang out” with people she liked anyway. She wasn’t a prostitute.

Me: Interesting distinction.

Lance Corporal Horny-No-More had developed a painful discharge, and needed to be cultured (the dreaded “rod”) and we threw in a syphilis test and an HIV (called a “high five” by every soldier I’ve met) for good measure. I spent a good 5 minutes telling this marine how absolutely, mind-numbingly stupid he had been. I gave him a spiel which has become almost second nature to me: channeling my inner “House, MD,” I berated his lack of any forethought, and described in painful detail the many diseases which might just become perpetual gifts for him (HIV, herpes, genital warts, syphilis), as well as the disgusting disease which he currently had (gonorrhea, possibly chlamydia as well). His ruddy complexion became more and more pale as I spoke, and in the end I seriously thought he might cry. He got his two grams of azithromycin (cephalosporin allergy), and hit the road, visibly shaken. (Good.)

A second patient had a unique problem: he had some pain in his right ear, which had become worse over the past month. Also, he said it sounded like everything was muffled, “like people are talking to me through a tunnel.” Pretty good description, that; the guy should be a writer. My medic told me that she looked in his ear and saw something that looked like (as I heard it) a “konk.”

Me: A what?

Medic: A “konk”

Me: What is a “konk”?

Medic: One of those shells that you can blow into and make noise.

Me (light-bulb over my head): Oh, a conch! [pronounced "konk"]

Medic: Yup.

I figured that this Army SPC had some cerumen (ear wax) which just happened to have taken on an unusual shape, so I looked in his ear. “You seem to have some sort of shell in there.”

Unbelievingly, the SPC asked me “What kind of shell?”

“It appears to be a tiny conch” I offered.

“What is a konk?” asked SPC Conch-ear.

“I’ll show you.”

A set of tweezers, a flashlight and a couple of minutes later, and the offending foreign body had been removed. And I do mean “body.” This soldier, who had admittedly slept on the beach, had not been able to bathe regularly, and who was now on his second deployment—this guy had (I kid you not) a tiny hermit crab in his ear.

And it was alive.

Now I have never been big into photography. Too many hassles and too much telling your friends to pose for my liking. But on this day, I cursed myself for not having brought my camera into the clinic. I talked with the patient, and he denied having ever felt something crawl up there, nor having come into any known contact with a hermit crab. But he had, indeed, “lived hard” over the past few years, sleeping in trenches, foxholes, and OPBs (Other People’s Beds) on a not-infrequent basis. Presumably, he picked up his little saprophytic buddy sometime during those travels, and it had lived in his auditory canal, living off of cerumen, and basking in the humidity and warmth there. Not a bad gig. If our Siamese cat Mimba could possibly live in someone’s ear, she probably would.

When all was said and done, I put this patient on some antibiotics for a concurrent outer ear infection, and asked him to come back on Monday. You can bet that I’ll have my camera with me, and will get a picture of that crab up in a blog post STAT.

After the patient had gone home, I thought of the one burning clinical question which I should have asked him before he hit the road, to wit:

Me: When you had that shell up there right inside your ear, did you “hear the ocean” on that side?

Inquiring minds want to know.

Well, I just gained a bit of free time, after turning on the telly and discovering that the fine people at FOX expect me to sit through two hours of being teased, advertised to, and cliffhung before they will let me know which of the Davids gets the prize. Truth is, though I tried to be careful today, I came across the name of the winner this afternoon (thanks iTunes!), so even the suspense is gone for me now. I had been willing to dedicate an hour to this, but two? Not gonna happen.

So, that gives me time to rant on a pressing Iraq-specific topic, and then we shall make a visit to the Rupard Mailbag.

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There are a few days in the week where I work out in the AM, at lunch, and in the PM after work. This has to do with the vagaries of my schedule here, which mandates that I take the work-out times when I can get them, because I know that on some days I will never get to put on a pair of tennis shoes. The result of all of this (when combined with the 110-plus heat which has settled in) is that I take a lot of showers, often three per day. Just before settling down to write this, I took one of these third showers, and was reminded of just how unsatisfying it is to “clean up” in this place.

First of all, the showers have absolutely NO water pressure. The amount of water that drips over my dust-encrusted skin ranges from a trickle to a drip. The trickle is bad—it is very hard to get soap on (or off) of one’s body without a reasonable amount of water to help out. The drip? Downright unusable. Soldiers have been known to run out of a dripping shower, wearing nothing but a towel and grab a couple of drinking water bottles from the pallet behind the latrine, so that they can get the soap off of their bodies. I have learned that if I wait it out long enough, the trickle will return. This is not always convenient, as often I am trying to grab a quick shower before heading back to work, but it is better than wiping the soap off of my skin with a towel, or turning into an unintentional streaker.

This, however, is not the least-attractive quality of our shower systems here on Al Asad. Not by a long shot. As is the case at home (but to a greater degree), the water temperature here is subject to wide and inexplicable variations. Lorri and the kids at home secretly enjoy it every time I hop in the shower, because they know they will eventually hear the chorus of moans and groans (with the occasional “yelp”) as the temperature changes on me, freezing my pasty white skin one moment and scalding me the next. In fact, I am pretty sure that some of this is instigated by the aforementioned “loved ones,” whom I suspect (but cannot prove), engage in some liberal flushing every time I bathe.

On post here, it is much worse. The water constantly, constantly fluctuates, from boiling to freezing, with nothing in between. At home I yelp intermittently. Here, I have developed a sort of anticipatory shower scaldofreezophobia, and now I just start screaming “aaaaaaaaaugh!” while I am getting undressed. This continues as I walk into the shower, and my scream persists through the burns and frostbite, and then as I am drying off, and while I am getting dressed afterwards. I stop screaming for a moment when I brush my teeth, and then it starts again as I walk back to my room. In fact, it is now an hour after my shower, and I am still screaming (aaaaaaaaugh!) as I write this.

Wish you were here.

——————-

Packages arrived over the past two days from four different senders, each of whom I wish to sincerely thank.

Package #1 was from the “AG Family,” who have so generously sent four or five other previously. This one was a large box filled with many pounds of different varieties of beef jerky, which is one of the soldiers’ staples out here, and not available at the mess hall. This sender has e-mailed me and prefers to remain anonymous, at least for now. Thanks to you, and please allow me to thank you publicly for you continued kindness and support of our clinic. The jerky is being enjoyed by all.

Package #2: From Lorri, included some cinnamon rolls which lasted about 3 minutes (no exaggeration) after I pulled them out of the box. Lorri, they were still fresh, and a very satisfying reminder of home. The package also included some drink mixes to keep my homies hydrated (love those crystal light packages) and some PB M&Ms. Thanks, sweetie!

Package #3, from one Aimee Seamons and family. This one included another bag of PB M&Ms (guess my “subtle” hints got through), a bunch of great books for our library, and a bag of powdered doughnuts, which is currently being preserved in my fridge, and will be broken out during our next “movie night.” I may share some of them. Thanks, Audrey, Gracie, Sulley, Aimee, and Quin.

Last but not least, the fourth package came from my friend and former EQ presidency member, Craig Ainsworth and his family. Some good music (thanks!), a couple of boxes of Entenmann’s treats (one of the few things that can make me stop “aaaugh”-ing at the moment), more drink mixes (woo-hoo!), and a couple of beautiful pieces of artwork for the clinic wall done by the Ainsworth kids. To Kathleen, Craig, Abbey, Owen, and Charlotte: thanks for your kindness. Thanks for thinking of us, and for thinking of me.

When I first arrived on Al Asad a few months ago, I was amazed to find that this military base has about a dozen stores which are run by Iraqis. These stores are known to the soldiers as “hadji” shops. The term “hadji” in Arabic refers to a holy man (sort of the Islamic equivalent of “guru”), but among the soldiers here, it is often used to refer to any and all things Iraqi. As an example, there was a controversial (and truly horrible) song which was recorded right here on Al Asad called “Hadji Girl” which tells the story of a soldier who fall in love with a local Iraqi girl, with predictably dire consequences. And on this blog a few days ago, an anonymous commenter referred to a foreign national as a “haji.”

The hadji shops are mostly clumped under and around the stadium, and have a very home-made look about them, like this:

In these shops, one will find a very friendly proprietor (usually a twenty-something Iraqi male) who is eager to serve. Items for sale in the shops range from satellite dishes (a few of my medics have bought these along with a programming package which gives them BBC channels and a few others, most in Arabic or in English with Arabic subtitles), to bootleg DVDs (poor-quality home-made camera shots of current movies, like Iron Man), to transformers, gun holders, combat boots, bikes, and cheap souvenirs. There is also a whole lot of random stuff in these store, including clearly broken/burnt-out stereos which carry sticker prices similar to what they must have cost when brand new. (Does anyone actually buy those?) One can also find strange drinks with Arabic writing on them, tobacco products, and other bits of randomness. In one of the stores, I found hundreds of silver-dollar-sized coins with the logos of American colleges pressed into them and painted. (Yes, I did look for a BYU coin, and yes, I did find one. Think about that for a moment: a Brigham Young University coin in a store run by Iraqis, on a military base in the middle-east. How did it get here? Why?)

The hadji shops only take cash, and each has a permit on the wall, stating that they have been allowed to sell their goods on post. Some soldiers love hanging out near the hadji shops, and spending their dough on the strange foreign stuff. I have yet to spend any money there, though I may buy a few things when I am getting closer to the end of my deployment.

There are a few other shops of interest on Al Asad, including an AAFES (Army and Air Force Exchange Service, the DoD-owned agency which runs the military “PX” exchange stores) “Carpet Shop.”

These carpet shops are a fixture on military bases in the middle east, and they sell authentic (or at least, authentic-looking and authentically expensive) Persian rugs which can be purchased and shipped home. I’ve yet to set foot in one of these stores.

Also on-post here is a store which sells impressive-looking and very expensive Turkish suits and other clothing, with the wonderfully generic (and wonderfully authentic foreign) name, the “Daylight Shoping Center.” I caught this picture of the “Daylight” at twilight.