Yesterday morning, a gap appeared in my schedule for the first time in 14 months; tuberculosis rounds skipped a weekly meeting as we begin winding down our strenuous efforts to battle a tuberculosis outbreak in Yellowknife’s homeless population. Finding patients, dealing with substance abuse and adjusting regimens for toxicity often seemed straightforward in comparison to the task we were given by local administrators: prevent the next outbreak.
For nearly 5 years, a small collection of hospital and Public Health staff have met twice a month to review all TB cases in the Northwest Territories. Although I chair the group, I began with very little knowledge of the disease and its treatment. I was willing, however, to serve as a figurehead (being the only physician), to ensure a connection between Public Health, community nurses and hospital staff as patients moved between the hospital and the community during their long treatment courses.
In the process, a wealth of knowledge gradually rubbed off on me as the lab staff, community nurses, infection control nurse and TB program coordinator all contributed their perspectives to patients’ care. Since all of the TB players were around the table, we also began adjusting our standing orders, hospital policies and communication pathways to better suit the needs that we identified in the course of patient care. We had no terms of reference, no budget and no official status in the hospital; life was good under the radar.
Then came the outbreak - and with it some finger-pointing between health boards, since the index case was missed for at least 6 months. Contact tracing identified hundreds of individuals potentially exposed to tuberculosis, many of whom had no phone number or fixed address. For years, I had been trying to keep TB on the agenda of physicians and administrators, pointing out the high rates in the NWT of both latent and active disease. Suddenly, everyone was interested in tuberculosis, and our little rounds group had to grow up, with terms of reference, a reporting structure, and minutes of our “systems rounds” where we left no stone unturned in examining the barriers to TB diagnosis and treatment.
An astute nurse pointed out that the first 6 cases had all slept in the same room at the local shelter, for a minimum of 5 nights out of the 2 weeks prior to the index case being diagnosed. In response, the TB program coordinator asked for an inspection of the shelter’s ventilation, and we worked closely with shelter staff to choose a new air filtration system – then lobbied the Department of Health to pay for it. The shelter staff were trained to be “cough monitors” – common in developing countries but not often used in Canadian TB control programs – (unless you happen to live in Yellowknife).
The infection control nurse pointed out that our isolation strategy would quickly overload our hospital’s resources, if several patients were simultaneously on treatment or under investigation. The Medical Health Officer (now an enthusiastic rounds participant) researched and developed a new isolation policy. “Coming soon to a hospital near you… a portable sputum induction isolation booth!” she announced, as we oohed and aahed over the glossy photos – and again, lobbied for the necessary funds to be released.
And what about the jail? Our TB patients often spent time in corrections, so the relevant nurses called in to meetings to confirm continuity in treatment regimens. We streamlined communications, and drafted a protocol for treatment of latent TB within the correctional system so that no opportunity (especially a 4-month prison sentence) will be missed in the prevention of active disease.
One of the emergency room physicians offered his department’s help in the investigation of contacts. “I know all these people you’re looking for,” he told a Public Health nurse. “I stitch up their cuts on Saturday nights. Just tell me what you need, and I’ll start getting sputum samples.” Designing an interdepartmental flagging system was complicated, but we tiptoed through the confidentiality and information transfer issues until a practical, ethical solution was found. In retrospect, this initiative alone would have prevented the Yellowknife outbreak, since the index patient sought care multiple times in the ER and various clinics; but there had been no way to flag his need for sputum samples.
To create a body of physicians comfortable with treating TB, I offered a 6-week course on Saturdays to interested nurses and doctors. Surrounded by journal articles, case summaries, and the Canadian TB Standards one Friday evening, I wondered how I found myself in this position. I think the call of the rural physician will always be, “Do what needs to be done.” Sometimes that means writing letters about ventilation systems, or visiting the nurses at the jail, or simply educating myself to do the task at hand. There is expertise and help, if we can recognize it in a shy lab technician or a shelter worker; but these unsung heroes often need a physician’s support to make their voices heard, and to see their work come to fruition.
Friday, August 1, 2008
Monday, July 28, 2008
A visit to my favourite little northern town
This morning, I will board a plane for Fort Simpson, a community of about 1200 people that I have visited every 2 months for the last 6years. From clinic, I drive 7 minutes to the airport, arriving at 9:55 for my 10:30 flight. (Although we have a fancy security system for flights going south to Edmonton, it’s not used for flights within the north.) I arrive in the 1-room Fort Simpson airport 45 minutes later, having been fed and watered 4 times by the flight attendant; she had only 12 passengers to look after today, and apparently a large surplus of food to dispense.
Upon landing, I retrieve the heavy metal suitcase that houses a pacemaker programmer, musing that every upgrade makes these machines heavier -- the opposite of most computerized technology. I suppose they aren’t designed for carting around the Arctic. A familiar voice begins greeting everyone in the airport; it’s Dale, the driver with a cackly laugh and a filthy truck who the bed & breakfast sends to pick me up when the hosts are busy. Dale swings my fragile luggage into the back of his pickup truck and we head down the highway, chatting about the weather, his wife’s health, and recent bear sightings in the area.
The health centre is run by a team of nurses, who provide first-line care and decide who needs to see the doctor. One nurse handles prenatal care and well-woman clinic; another runs the walk-in sick clinic, another the chronic disease program, and so on. Every few years they rotate programs to maintain skills, and each morning at sign-out the nurse-on-call presents the previous night’s cases to her nursing and physician colleagues. At morning report, new nurses receive a crash course in northern medicine: “Fred came in coughing? He needs a sputum for TB; he’s on the high-risk list. And if Joey has a boxer’s fracture, chances are that Sonny has a broken jaw; they were arguing outside the bar last night. We’ll ask Home Care to stop by his place.”
The chronic disease nurse runs the internal medicine travel clinic, and it is indeed a tight ship. Every diabetic has a recent glycosylated hemoglobin on the chart, and no one seems to forget their medications -- unlike my clinic in Yellowknife. If I ask for a blood test, an ECG and a chest x-ray, my nurse performs all of the tests herself and leaves the film on the viewbox for me to review. Any social background I request on a patient is answered by colourful stories of community life -- generally more detailed than I would like to know, but interesting nonetheless.
Monday afternoon I see patients from Wrigley; Tuesday morning includes Fort Liard and Jean Marie River, and the occasional consult patient is flown in from Nahanni Butte. These tiny communities actually view Fort Simpson as a regional centre, and some are served only by an on-site lay health worker, with fly-in nurse visits every month or so.
One of the more unusual clinics greeted me the first time I came to Fort Simpson; I commented on the number of dogs in the waiting area, and the nurse told me it was Lois’ clinic day. “Is she a vet?” I asked. “Oh no, she’s the long-term care nurse but she takes care of doggy shots and boo-boos on her days off. There’s no vet in town, and we figured she could use the clinic space once every couple of weeks.” Who was I to argue?
Lois took a turn at managing the internal medicine clinic a few years ago, and I commented that I was concerned about the social isolation of a patient I followed for congestive heart failure. “He’s so young, Lois, and I don’t think he has any personal connections to keep him going,” I commented as I represcribed his medications. She nodded thoughtfully, and a couple of months later she told me he was doing much better. “Did he meet someone?” I asked hopefully. Lois leaned forward, her eyes twinkling. “I gave him a kitten,” she told me earnestly. “He carries her everywhere, even to the grocery store. He just adores her, and she’s had all of her shots.” The thought of my corpulent patient lavishing affection on a tiny kitten made me laugh outright; but I couldn’t ask for more holistic care.
A few years ago, Fort Simpson was blessed with a remarkable physician who served the community half-time, spending the rest of his year at his family’s ranch on Salt Spring Island. Shane invested heavily in nurse education, and the bulletin boards in examining rooms are covered with the protocols he wrote up for the diagnosis and treatment of common conditions. Strep throat scoring systems, first-line therapy for UTI’s (including who needs a culture), antibiotic protocols for cellulitis, and prenatal visit guidelines jostle for space among various notices from the Yellowknife specialist clinics.
Among the protocols is a tiny scrap of paper titled “the internist”, with my cell phone number underneath. Apparently Fort Simpson doesn’t consult the call schedule; and in truth, I would rather be the one to find out if a familiar patient runs into problems. The doctor’s office even has a photo of “the internist” with her jolly redheaded baby, enjoying a holiday in the south of France. Jeannine, the nurse who runs the bed & breakfast, always stops by to chat or offer me a drink after clinic. And if I still lacked a sense of social belonging, in my favorite little northern town, I’m sure Lois would find me a kitten.
Upon landing, I retrieve the heavy metal suitcase that houses a pacemaker programmer, musing that every upgrade makes these machines heavier -- the opposite of most computerized technology. I suppose they aren’t designed for carting around the Arctic. A familiar voice begins greeting everyone in the airport; it’s Dale, the driver with a cackly laugh and a filthy truck who the bed & breakfast sends to pick me up when the hosts are busy. Dale swings my fragile luggage into the back of his pickup truck and we head down the highway, chatting about the weather, his wife’s health, and recent bear sightings in the area.
The health centre is run by a team of nurses, who provide first-line care and decide who needs to see the doctor. One nurse handles prenatal care and well-woman clinic; another runs the walk-in sick clinic, another the chronic disease program, and so on. Every few years they rotate programs to maintain skills, and each morning at sign-out the nurse-on-call presents the previous night’s cases to her nursing and physician colleagues. At morning report, new nurses receive a crash course in northern medicine: “Fred came in coughing? He needs a sputum for TB; he’s on the high-risk list. And if Joey has a boxer’s fracture, chances are that Sonny has a broken jaw; they were arguing outside the bar last night. We’ll ask Home Care to stop by his place.”
The chronic disease nurse runs the internal medicine travel clinic, and it is indeed a tight ship. Every diabetic has a recent glycosylated hemoglobin on the chart, and no one seems to forget their medications -- unlike my clinic in Yellowknife. If I ask for a blood test, an ECG and a chest x-ray, my nurse performs all of the tests herself and leaves the film on the viewbox for me to review. Any social background I request on a patient is answered by colourful stories of community life -- generally more detailed than I would like to know, but interesting nonetheless.
Monday afternoon I see patients from Wrigley; Tuesday morning includes Fort Liard and Jean Marie River, and the occasional consult patient is flown in from Nahanni Butte. These tiny communities actually view Fort Simpson as a regional centre, and some are served only by an on-site lay health worker, with fly-in nurse visits every month or so.
One of the more unusual clinics greeted me the first time I came to Fort Simpson; I commented on the number of dogs in the waiting area, and the nurse told me it was Lois’ clinic day. “Is she a vet?” I asked. “Oh no, she’s the long-term care nurse but she takes care of doggy shots and boo-boos on her days off. There’s no vet in town, and we figured she could use the clinic space once every couple of weeks.” Who was I to argue?
Lois took a turn at managing the internal medicine clinic a few years ago, and I commented that I was concerned about the social isolation of a patient I followed for congestive heart failure. “He’s so young, Lois, and I don’t think he has any personal connections to keep him going,” I commented as I represcribed his medications. She nodded thoughtfully, and a couple of months later she told me he was doing much better. “Did he meet someone?” I asked hopefully. Lois leaned forward, her eyes twinkling. “I gave him a kitten,” she told me earnestly. “He carries her everywhere, even to the grocery store. He just adores her, and she’s had all of her shots.” The thought of my corpulent patient lavishing affection on a tiny kitten made me laugh outright; but I couldn’t ask for more holistic care.
A few years ago, Fort Simpson was blessed with a remarkable physician who served the community half-time, spending the rest of his year at his family’s ranch on Salt Spring Island. Shane invested heavily in nurse education, and the bulletin boards in examining rooms are covered with the protocols he wrote up for the diagnosis and treatment of common conditions. Strep throat scoring systems, first-line therapy for UTI’s (including who needs a culture), antibiotic protocols for cellulitis, and prenatal visit guidelines jostle for space among various notices from the Yellowknife specialist clinics.
Among the protocols is a tiny scrap of paper titled “the internist”, with my cell phone number underneath. Apparently Fort Simpson doesn’t consult the call schedule; and in truth, I would rather be the one to find out if a familiar patient runs into problems. The doctor’s office even has a photo of “the internist” with her jolly redheaded baby, enjoying a holiday in the south of France. Jeannine, the nurse who runs the bed & breakfast, always stops by to chat or offer me a drink after clinic. And if I still lacked a sense of social belonging, in my favorite little northern town, I’m sure Lois would find me a kitten.
Thursday, July 24, 2008
To soar, or simply to survive
This weekend, after 6 years in Yellowknife, I finally joined local aviation enthusiasts for the city’s annual air show.
I went for my son’s benefit, but I will never miss the show again. My 2-year-old ran wildly in circles among the planes near the hangar, trying out one cockpit after another and gleefully crowing to me from the windows: “Mummy! I’m in the plane! I’m in the plane!”
Since my husband has more energy than I do these days, he did most of the chasing while I watched the aerial performances — mesmerized by the beauty of a single plane in its huge playground of sky, rolling and twisting its way through figure-eights simply for the joy of flying.
The north has a love affair with flying, and with the pilots that opened this land to development and discovery over the last century. The local heroes (except for prospectors, hunters, and community nurses) are often the pilots who could fly in the most desperate of circumstances, fix their own planes if needed, and wisely recognize their own limitations in extreme weather conditions.
Preparedness is essential, and even a business traveler on Air Tindi will be refused boarding in February if the flight crew don’t think his parka is adequate. Some flights to my travel clinics have only a pilot and co-pilot, who calmly explains where to find the emergency transmitter and survival gear in the event of an unforeseen landing. When a flight attendant is present, passengers are treated like royalty; no first class is necessary, since everyone is fed and generally spoiled on even a 45-minute, mid-morning flight.
Northern pilots and medical staff are inextricably linked, since we frequently collaborate to bring patients from far-flung communities and camps to a point of medical care.
More difficult, though, is the relation of a physician to a pilot as a patient. How can I hope to obtain an accurate blood pressure in clinic, when the pilot knows he will be grounded until I certify him as healthy and ready to fly?
A young man who spent his entire life longing to fly, and training as a commercial pilot, was recently diagnosed with diabetes. My role, at his second clinic visit, was to confirm his worst fears — he would need insulin to control his blood glucose, and would never fly again.
Another pilot, who lives with his wife and children on a remote homestead surrounded by wilderness, was grounded when an ECG showed inferior Q waves. Although he was only grounded for a week (until I repeated the ECG with more careful lead placement and performed a stress test), he faced the possibility of giving up his home, his lifestyle and his profession since even a trip to town for groceries depended on his pilot license.
My greatest fear for a pilot is that he or she will not seek medical help in a timely manner, due to fear of being grounded.
When I was still quite new to Yellowknife, I was called to a code in the emergency room for the husband of our finest critical care nurse. He had been mentioning some arm pain for a week, but wouldn’t seek medical attention. He shoveled the driveway one morning, drove to the airport, and was stopped for driving erratically — fortunately before he strapped on his pilot gear and put other lives in danger.
By the time he arrived in Emergency, the pilot was asystolic and could not be resuscitated.
My colleague was now a young widow with children, all because of a pilot’s fear of losing his license.
His career had included flights to Antarctica and he was head pilot for the toughest employer in the north. His employer’s father, 82-years-old, was recovering in hospital from an uncomplicated myocardial infarction on the day that pilot was brought in. During rounds, I spoke with the weathered airline boss – he flies DC-3’s and looks as tough and indestructible as those planes.
“Yeah, they brought in my head pilot today,” he commented, looking past his elderly father. “Forty-three years old. Makes you wonder.”
The memorial service was held in the huge hangar at the airport, and the deceased pilot was honoured with a fly-by of his own plane.
I was still new to the aviation culture, and much of what was said in the service was beyond my comprehension.
But I realized that aviation seems to mirror the landscape of the north in many ways — with its power and fragility, its complexity and grace, its very human desire to soar — or simply to survive.
And perhaps, to that extent, it’s a lot like medicine too.
I went for my son’s benefit, but I will never miss the show again. My 2-year-old ran wildly in circles among the planes near the hangar, trying out one cockpit after another and gleefully crowing to me from the windows: “Mummy! I’m in the plane! I’m in the plane!”
Since my husband has more energy than I do these days, he did most of the chasing while I watched the aerial performances — mesmerized by the beauty of a single plane in its huge playground of sky, rolling and twisting its way through figure-eights simply for the joy of flying.
The north has a love affair with flying, and with the pilots that opened this land to development and discovery over the last century. The local heroes (except for prospectors, hunters, and community nurses) are often the pilots who could fly in the most desperate of circumstances, fix their own planes if needed, and wisely recognize their own limitations in extreme weather conditions.
Preparedness is essential, and even a business traveler on Air Tindi will be refused boarding in February if the flight crew don’t think his parka is adequate. Some flights to my travel clinics have only a pilot and co-pilot, who calmly explains where to find the emergency transmitter and survival gear in the event of an unforeseen landing. When a flight attendant is present, passengers are treated like royalty; no first class is necessary, since everyone is fed and generally spoiled on even a 45-minute, mid-morning flight.
Northern pilots and medical staff are inextricably linked, since we frequently collaborate to bring patients from far-flung communities and camps to a point of medical care.
More difficult, though, is the relation of a physician to a pilot as a patient. How can I hope to obtain an accurate blood pressure in clinic, when the pilot knows he will be grounded until I certify him as healthy and ready to fly?
A young man who spent his entire life longing to fly, and training as a commercial pilot, was recently diagnosed with diabetes. My role, at his second clinic visit, was to confirm his worst fears — he would need insulin to control his blood glucose, and would never fly again.
Another pilot, who lives with his wife and children on a remote homestead surrounded by wilderness, was grounded when an ECG showed inferior Q waves. Although he was only grounded for a week (until I repeated the ECG with more careful lead placement and performed a stress test), he faced the possibility of giving up his home, his lifestyle and his profession since even a trip to town for groceries depended on his pilot license.
My greatest fear for a pilot is that he or she will not seek medical help in a timely manner, due to fear of being grounded.
When I was still quite new to Yellowknife, I was called to a code in the emergency room for the husband of our finest critical care nurse. He had been mentioning some arm pain for a week, but wouldn’t seek medical attention. He shoveled the driveway one morning, drove to the airport, and was stopped for driving erratically — fortunately before he strapped on his pilot gear and put other lives in danger.
By the time he arrived in Emergency, the pilot was asystolic and could not be resuscitated.
My colleague was now a young widow with children, all because of a pilot’s fear of losing his license.
His career had included flights to Antarctica and he was head pilot for the toughest employer in the north. His employer’s father, 82-years-old, was recovering in hospital from an uncomplicated myocardial infarction on the day that pilot was brought in. During rounds, I spoke with the weathered airline boss – he flies DC-3’s and looks as tough and indestructible as those planes.
“Yeah, they brought in my head pilot today,” he commented, looking past his elderly father. “Forty-three years old. Makes you wonder.”
The memorial service was held in the huge hangar at the airport, and the deceased pilot was honoured with a fly-by of his own plane.
I was still new to the aviation culture, and much of what was said in the service was beyond my comprehension.
But I realized that aviation seems to mirror the landscape of the north in many ways — with its power and fragility, its complexity and grace, its very human desire to soar — or simply to survive.
And perhaps, to that extent, it’s a lot like medicine too.
Monday, July 21, 2008
The intersection of faith, family and survival
Bill’s daughter Mary is worried about him again. He is elderly and she fears he is over-committed in the community, considering his multiple medical problems.
She hasn’t approached me this time with her concerns, but it seems I cannot escape them, it being a small community. On Sunday at lunch, I am sitting at the corner table of the “Chinese-Western Diner,” feasting with my family on wonton soup, grilled cheese with ketchup, and buttermilk pancakes. A mutual friend approaches and asks me, as Bill’s physician, whether I think he should slow down, and in particular, cancel a bible study group that meets Fridays at 7 a.m. at a tiny local church.
I weigh my words carefully, wanting to protect the dignity and confidentiality of all involved — but particularly my friend, mentor and patient. “Well, I think Bill is in the best position to decide how he wishes to spend his energies, and I’m sure he’ll consider (well, consider, then happily ignore, judging from prior experience) his family’s concerns.”
“Great,” she responds with a smile; “See you Friday at seven.”
I turn back to my husband Paul, who stifles a chuckle. “It must be hard for Mary to sleep in when Bill is shuffling around the house at 6 a.m. on Fridays,” is his only comment.
Paul loves Friday mornings as much as I do; after bible study at church, I drive Bill back to our house, where Paul reads to him for an hour or so over tea. Bill still subscribes to his favorite magazines, despite losing his vision to macular degeneration, and Paul enjoys the excuse to read archaeology, history and international news with a good friend.
During residency, I was frequently warned not to serve as a friend’s physician, but my perspective shifted after moving north. It has been said that in a small community, physicians who won’t treat their friends have either no friends or no patients.
Yellowknife is large enough to balance these approaches, depending on the situation; and Bill has always preferred to be under the care of someone he knows and trusts as a friend. At times I have distanced myself from his care, insisting he also have a family physician and stepping out while a colleague on call prepared for a transvenous pacemaker insertion.
The hardest area has been discussion of code status. After a particularly difficult year — punctuated by repeated hospitalizations and a few medevacs — we addressed the topic in the comfort of my clinic.
I felt foolish outlining the question to a minister who traveled 3000 kilometers per year by dogsled in “the early days,” witnessing Inuit families torn apart by tuberculosis treatment and conducting funerals for infants who died on the trail during Arctic migrations. Bill understands human fragility far better than I do, and has had 50 years in the Arctic to reflect on the intersection of faith, family and survival.
He nodded slowly, and smiled.
“Yes, I understand what you are asking. I trust you and your colleagues to make the right decision, and I hope that the physicians looking after me would contact you and speak with my family as well.”
In his own wise way, he sidestepped the easy questions — tube or no tube? CPR or not? — and yet provided exactly what I needed to know.
Clinical situations change, but the guiding principles of his life – which he knows I share – will ensure that he lives and dies with grace, dignity, and hope. The best I can do for his code status is to advise: “Be sensible, be compassionate, and please call me.”
She hasn’t approached me this time with her concerns, but it seems I cannot escape them, it being a small community. On Sunday at lunch, I am sitting at the corner table of the “Chinese-Western Diner,” feasting with my family on wonton soup, grilled cheese with ketchup, and buttermilk pancakes. A mutual friend approaches and asks me, as Bill’s physician, whether I think he should slow down, and in particular, cancel a bible study group that meets Fridays at 7 a.m. at a tiny local church.
I weigh my words carefully, wanting to protect the dignity and confidentiality of all involved — but particularly my friend, mentor and patient. “Well, I think Bill is in the best position to decide how he wishes to spend his energies, and I’m sure he’ll consider (well, consider, then happily ignore, judging from prior experience) his family’s concerns.”
“Great,” she responds with a smile; “See you Friday at seven.”
I turn back to my husband Paul, who stifles a chuckle. “It must be hard for Mary to sleep in when Bill is shuffling around the house at 6 a.m. on Fridays,” is his only comment.
Paul loves Friday mornings as much as I do; after bible study at church, I drive Bill back to our house, where Paul reads to him for an hour or so over tea. Bill still subscribes to his favorite magazines, despite losing his vision to macular degeneration, and Paul enjoys the excuse to read archaeology, history and international news with a good friend.
During residency, I was frequently warned not to serve as a friend’s physician, but my perspective shifted after moving north. It has been said that in a small community, physicians who won’t treat their friends have either no friends or no patients.
Yellowknife is large enough to balance these approaches, depending on the situation; and Bill has always preferred to be under the care of someone he knows and trusts as a friend. At times I have distanced myself from his care, insisting he also have a family physician and stepping out while a colleague on call prepared for a transvenous pacemaker insertion.
The hardest area has been discussion of code status. After a particularly difficult year — punctuated by repeated hospitalizations and a few medevacs — we addressed the topic in the comfort of my clinic.
I felt foolish outlining the question to a minister who traveled 3000 kilometers per year by dogsled in “the early days,” witnessing Inuit families torn apart by tuberculosis treatment and conducting funerals for infants who died on the trail during Arctic migrations. Bill understands human fragility far better than I do, and has had 50 years in the Arctic to reflect on the intersection of faith, family and survival.
He nodded slowly, and smiled.
“Yes, I understand what you are asking. I trust you and your colleagues to make the right decision, and I hope that the physicians looking after me would contact you and speak with my family as well.”
In his own wise way, he sidestepped the easy questions — tube or no tube? CPR or not? — and yet provided exactly what I needed to know.
Clinical situations change, but the guiding principles of his life – which he knows I share – will ensure that he lives and dies with grace, dignity, and hope. The best I can do for his code status is to advise: “Be sensible, be compassionate, and please call me.”
Monday, July 14, 2008
The outpatient inmate
I received a fax this week from a corrections nurse in Saskatchewan, asking for details of a patient’s pacemaker so that he could receive appropriate follow-up at the pacemaker clinic closest to what I assume is a federal prison. I sighed – Bob was in trouble again – but at least he wouldn’t be selling drugs to teenagers in Yellowknife for the foreseeable future.
I remember distinctly the first time I met Bob; the GP on call consulted me from the emergency room for atrial fibrillation. A pleasant guard stood to the side while I asked Bob a few questions. “They think I’m faking it,” he told me defensively. “But my chest doesn’t feel right, especially when I lie down.” He had no medical history except for a pacemaker insertion a few months prior and took no medications. His distended neck veins and a soft precordial rub told me I wasn’t dealing with run-of-the-mill atrial fibrillation, and the chest x-ray showed almost a circular cardiac silhouette. We had no echo services, but fortunately the cardiologist in Edmonton agreed to see him if we sent him down by medevac for possible pericardiocentesis.
“I guess that means I’ll be going, too,” the guard commented politely. “How long do you think he’ll be in Edmonton?” I couldn’t tell him many details, but we arranged the flight; and I must admit I felt vindicated to learn that the skeptical cardiologist had removed several hundred ccs of fluid from the pericardium upon the patient’s arrival in Edmonton.
For months I didn’t see Bob again; he had been released from prison and tended not to come to appointments on his own accord. I did, however, see the guard again at a local coffee shop a few weeks later. We spoke briefly, and when he heard I was looking for a reliable old car, he directed me to a 12-year-old Subaru station wagon he had been thinking of buying. An amateur mechanic, he had considered its many selling points: “You know, Amy, I went hunting with one of my buddies who had a Subaru wagon. We got a huge moose, and the whole carcass fit in the back of that car! Great trunk capacity, those Subaru wagons.”
I was duly impressed and bought the car the next week. Although I haven’t used it for moose hunting, it was the designated transport vehicle for a double bass prior to a performance of Handel’s Messiah last Christmas. None of the choristers’ SUVs could squeeze in the bass and it was too cold (minus 43 without counting wind chill) to cart it around in a pickup truck.
When my patient surfaced again, he was back in corrections for drug dealing and some break-and-entry charges. (It’s hard not to notice when your patients keep showing up in the local newspaper.) He was clearly relieved to discuss his medications with me, specifically whether he needed to continue sotalol now that he had been free of palpitations for a few months. He also wanted to review options to treat his hepatitis C; I told him I would only consider initiating treatment if he was sober and out of jail for several months, or if he had at least a 1-year prison sentence to allow a full treatment course in corrections. He thanked me politely for my opinion “and for saving my life back in September.” I wondered privately what he intended to do with the life remaining to him, but kept my comments to myself.
Only once, in frustration during a clinic visit, did I tell Bob that it was difficult to care for someone who only came to appointments when incarcerated. “I’m tired of seeing your name in the papers,” I commented, and was surprised that he said nothing to defend himself. As a rural physician, it is very hard to ignore the impact that someone has on my small community. How many of my friends’ children have been tempted towards a path of destruction by my patient’s efforts, I will never know – nor would I dream of trying to find out. I can only hope to provide some degree of respect, hope and patience towards a man whom I have only ever encountered as a patient.
And that Subaru? Six years later, it’s still going strong. It needed a new transmission a few years ago, but the guard turned up again just in time to find me a great deal from a wrecking yard out of town. I guess I have my debts to Bob as well.
-- Dr. Amy Hendricks
I remember distinctly the first time I met Bob; the GP on call consulted me from the emergency room for atrial fibrillation. A pleasant guard stood to the side while I asked Bob a few questions. “They think I’m faking it,” he told me defensively. “But my chest doesn’t feel right, especially when I lie down.” He had no medical history except for a pacemaker insertion a few months prior and took no medications. His distended neck veins and a soft precordial rub told me I wasn’t dealing with run-of-the-mill atrial fibrillation, and the chest x-ray showed almost a circular cardiac silhouette. We had no echo services, but fortunately the cardiologist in Edmonton agreed to see him if we sent him down by medevac for possible pericardiocentesis.
“I guess that means I’ll be going, too,” the guard commented politely. “How long do you think he’ll be in Edmonton?” I couldn’t tell him many details, but we arranged the flight; and I must admit I felt vindicated to learn that the skeptical cardiologist had removed several hundred ccs of fluid from the pericardium upon the patient’s arrival in Edmonton.
For months I didn’t see Bob again; he had been released from prison and tended not to come to appointments on his own accord. I did, however, see the guard again at a local coffee shop a few weeks later. We spoke briefly, and when he heard I was looking for a reliable old car, he directed me to a 12-year-old Subaru station wagon he had been thinking of buying. An amateur mechanic, he had considered its many selling points: “You know, Amy, I went hunting with one of my buddies who had a Subaru wagon. We got a huge moose, and the whole carcass fit in the back of that car! Great trunk capacity, those Subaru wagons.”
I was duly impressed and bought the car the next week. Although I haven’t used it for moose hunting, it was the designated transport vehicle for a double bass prior to a performance of Handel’s Messiah last Christmas. None of the choristers’ SUVs could squeeze in the bass and it was too cold (minus 43 without counting wind chill) to cart it around in a pickup truck.
When my patient surfaced again, he was back in corrections for drug dealing and some break-and-entry charges. (It’s hard not to notice when your patients keep showing up in the local newspaper.) He was clearly relieved to discuss his medications with me, specifically whether he needed to continue sotalol now that he had been free of palpitations for a few months. He also wanted to review options to treat his hepatitis C; I told him I would only consider initiating treatment if he was sober and out of jail for several months, or if he had at least a 1-year prison sentence to allow a full treatment course in corrections. He thanked me politely for my opinion “and for saving my life back in September.” I wondered privately what he intended to do with the life remaining to him, but kept my comments to myself.
Only once, in frustration during a clinic visit, did I tell Bob that it was difficult to care for someone who only came to appointments when incarcerated. “I’m tired of seeing your name in the papers,” I commented, and was surprised that he said nothing to defend himself. As a rural physician, it is very hard to ignore the impact that someone has on my small community. How many of my friends’ children have been tempted towards a path of destruction by my patient’s efforts, I will never know – nor would I dream of trying to find out. I can only hope to provide some degree of respect, hope and patience towards a man whom I have only ever encountered as a patient.
And that Subaru? Six years later, it’s still going strong. It needed a new transmission a few years ago, but the guard turned up again just in time to find me a great deal from a wrecking yard out of town. I guess I have my debts to Bob as well.
-- Dr. Amy Hendricks
Thursday, July 10, 2008
Rural medicine lessons for residents
Last week marked a new rotation in the academic medicine schedule, and 2 residents landed in Yellowknife to begin their rural internal medicine rotations. One of them joined me yesterday for clinic. By the end of the morning, he asked if he could ask me a “program” question. “I’m not sure I understand how you utilize subspecialists up here in Yellowknife,” he commented. “Do you call them for advice, or send patients down for consultation?”
I remembered my first few months in rural practice, which included several desperate phone calls back to McGill (where I had trained) for advice. During those days, I was intimidated by the clinic setting and spent hours each day checking notes and online education resources to ensure I was managing patients appropriately. Six years later, life has changed considerably.
“Well,” I replied, “I send patients down when they need a procedure – an MRI, cardiac catheterization, perhaps a MIBI scan. I’m not as strong at rheumatology or outpatient neurology these days, since we have excellent locums who come every 3 months and see patients from all over the north here in Yellowknife. I don’t usually send patients out for an opinion on a cardiology or diabetes patient, since we’re able to offer good service here in the north.”
He thought back over the morning. We had followed up a patient post-ablation for WPW, discussed pharmacologic and other options for SVT with a teenager and her mother, and reprogrammed the pacemaker of a patient from Ulukhaktok, a tiny hamlet on an island in the Arctic Ocean. I had spoken to an Edmonton specialist regarding changes to an outpatient tuberculosis regimen due to drug intolerance, and I was trying to book a pregnant type II diabetic within the next couple of days, to start her on insulin. The tuberculosis and pacemaker cases presented us with some good teaching opportunities, and we also discussed the benefits of continuous glucose monitoring systems in selected diabetic patients.
“I guess I didn’t expect all of this to happen in one place,” commented my resident. “I don’t think that’s what internists do in downtown Calgary, is it?” Having never worked in Calgary, I had no details to give him regarding the outpatient life of internists more familiar to him. “I’m sure that each of them has a practice profile suiting their expertise and meeting a need in their community,” was the best I could do.
I never chose tuberculosis, or pacemakers, or insulin pumps, as part of my job description; in a small community, a specialist’s role develops around local needs and to complement local expertise. Most gastroenterology questions are punted from my desk to a couple of colleagues down the hall, and they reciprocate with nephrology referrals since I work most closely with our dialysis and renal insufficiency programs.
In the afternoon, the resident joined me for stress testing, and we started out with a patient from the small community of Fort Smith. A young man with previous coronary bypass surgery and chronic atrial fibrillation, he clearly needed consistent care to prevent future cardiac events. I listed him for annual stress tests – not because they are necessarily indicated, but because they will guarantee he sees an internist at least annually to review his lipids, diabetes management, ventricular rate control, and cardiac status. “Fort Smith just lost its only permanent physician,” I explained to the resident, “so I can ask the nurses to watch his heart rate, lipids and so on – but I can’t guarantee continuity of physician coverage unless he’s kept in our system.”
The next patient, from Yellowknife, had been unable to find a family physician for months. He had a reassuring stress test but multiple cardiac risk factors. “Our nurse practitioner will follow up his lipids and smoking cessation,” I told the resident; “If anyone can help him stop smoking, it will be an ex-smoker who has plenty of time for phone and clinic follow-up.”
Sometimes it seems that every community in the Northwest Territories has a different model of care, which changes as local medical resources ebb and flow. My resident will soon board another plane for a 1-physician community, where the visiting internist is treated to lunch in exchange for a spontaneous lecture to the local nursing staff on the topic of their choice. He will see patients from the bush and patients from the town, and offer advice and encouragement to the nurses who give most of the medical care to the region’s scattered population.
Perhaps one day my resident (or one of his colleagues) will give himself to a small community, becoming the internist for an otherwise unserved population, learning and growing with local needs and programs. Granted, it is a model he has not seen before; but it is the only life I have known since I was foolhardy enough to accept a 1-way ticket here from Montreal. I do miss the opera, but otherwise I wouldn’t change a thing.
-- Dr. Amy Hendricks
I remembered my first few months in rural practice, which included several desperate phone calls back to McGill (where I had trained) for advice. During those days, I was intimidated by the clinic setting and spent hours each day checking notes and online education resources to ensure I was managing patients appropriately. Six years later, life has changed considerably.
“Well,” I replied, “I send patients down when they need a procedure – an MRI, cardiac catheterization, perhaps a MIBI scan. I’m not as strong at rheumatology or outpatient neurology these days, since we have excellent locums who come every 3 months and see patients from all over the north here in Yellowknife. I don’t usually send patients out for an opinion on a cardiology or diabetes patient, since we’re able to offer good service here in the north.”
He thought back over the morning. We had followed up a patient post-ablation for WPW, discussed pharmacologic and other options for SVT with a teenager and her mother, and reprogrammed the pacemaker of a patient from Ulukhaktok, a tiny hamlet on an island in the Arctic Ocean. I had spoken to an Edmonton specialist regarding changes to an outpatient tuberculosis regimen due to drug intolerance, and I was trying to book a pregnant type II diabetic within the next couple of days, to start her on insulin. The tuberculosis and pacemaker cases presented us with some good teaching opportunities, and we also discussed the benefits of continuous glucose monitoring systems in selected diabetic patients.
“I guess I didn’t expect all of this to happen in one place,” commented my resident. “I don’t think that’s what internists do in downtown Calgary, is it?” Having never worked in Calgary, I had no details to give him regarding the outpatient life of internists more familiar to him. “I’m sure that each of them has a practice profile suiting their expertise and meeting a need in their community,” was the best I could do.
I never chose tuberculosis, or pacemakers, or insulin pumps, as part of my job description; in a small community, a specialist’s role develops around local needs and to complement local expertise. Most gastroenterology questions are punted from my desk to a couple of colleagues down the hall, and they reciprocate with nephrology referrals since I work most closely with our dialysis and renal insufficiency programs.
In the afternoon, the resident joined me for stress testing, and we started out with a patient from the small community of Fort Smith. A young man with previous coronary bypass surgery and chronic atrial fibrillation, he clearly needed consistent care to prevent future cardiac events. I listed him for annual stress tests – not because they are necessarily indicated, but because they will guarantee he sees an internist at least annually to review his lipids, diabetes management, ventricular rate control, and cardiac status. “Fort Smith just lost its only permanent physician,” I explained to the resident, “so I can ask the nurses to watch his heart rate, lipids and so on – but I can’t guarantee continuity of physician coverage unless he’s kept in our system.”
The next patient, from Yellowknife, had been unable to find a family physician for months. He had a reassuring stress test but multiple cardiac risk factors. “Our nurse practitioner will follow up his lipids and smoking cessation,” I told the resident; “If anyone can help him stop smoking, it will be an ex-smoker who has plenty of time for phone and clinic follow-up.”
Sometimes it seems that every community in the Northwest Territories has a different model of care, which changes as local medical resources ebb and flow. My resident will soon board another plane for a 1-physician community, where the visiting internist is treated to lunch in exchange for a spontaneous lecture to the local nursing staff on the topic of their choice. He will see patients from the bush and patients from the town, and offer advice and encouragement to the nurses who give most of the medical care to the region’s scattered population.
Perhaps one day my resident (or one of his colleagues) will give himself to a small community, becoming the internist for an otherwise unserved population, learning and growing with local needs and programs. Granted, it is a model he has not seen before; but it is the only life I have known since I was foolhardy enough to accept a 1-way ticket here from Montreal. I do miss the opera, but otherwise I wouldn’t change a thing.
-- Dr. Amy Hendricks
Thursday, July 3, 2008
Words are not wasted when there is soup to deliver
Spring came reluctantly to Yellowknife this year, but finally the ice bridge over the Mackenzie River gave way to a ferry crossing, just in time for my new grand piano to travel by road from Kelowna.
I arrived home from work to find my friend and trusted piano dealer in my living room, after he had spent 3 days on the road with the piano. The next challenge was to wrestle the piano into our inaccessible living room.
Then the cell phone rang. I wasn’t on call, but I smiled when I heard a familiar voice: “Hello, it’s Anna from Home Care. I’m so sorry to bother you, but I can’t reach the physicians who have been following one of our palliative patients …”
The family physician was in an outlying community, and the locum covering his practice first tried to send the patient to the ER and then could not be reached by phone. The palliative care “call group” in Yellowknife consists of myself, anytime, as long as I can be reached, precisely because of situations like these.
The patient, a young father of 3, was dying at home of a malignancy. He had just been started on some morphine for respiratory distress, but Anna felt he would benefit from a benzodiazepine as well. I couldn’t give her a phone order for a patient I’d never seen, but we arranged for a home visit the next day — my day off, but I would welcome another commitment around the time that my piano would be dangling from a crane in the front yard.
Next came the delicate task of soliciting a consult. I cannot advertise myself as a palliative care specialist, but most family physicians accept my involvement through Home Care during their own absences, or in the event that a homebound patient requires internal medicine services. Yellowknife’s Home Care nurses are the local experts in symptom management, and they can usually wrangle a consult when needed. In this case, the family physician was happy to oblige.
Arriving at the little house the next day, I found the door open and walked in to find Karen, another nurse, at the kitchen table. The patient’s young wife, wearing pyjamas and a bandana, had more dignity and grace about her than many a suit-clad business type.
She handed me a plate of waffles, pointed to the syrup, and continued her discussion of which medications were really needed at this point.
A middle-aged, cheerful fellow walked in just after me, carrying a large pot. “Beef barley,” he told the patient’s wife. “There’s space in the fridge,” she replied; he deposited the soup and left with a nod and a kind smile.
Between mouthfuls of waffles, I made some suggestions for medications, and phoned the pharmacist. I spoke with the patient, who awoke from a snooze on the couch to smile warmly at his wife and submit to a brief examination.
I didn’t need to know much; he had no pain, was scared but trusting, wanted to stay home until he died, and felt better with tiny doses of morphine and the occasional sleeping pill. I would come back on the weekend for another visit.
Before the next visit, I was called again — this time to declare the patient deceased and fill out the relevant paperwork.
The house was sad but peaceful, and his wife still wore her dignity and tenderness — perfectly paired with overalls and a t-shirt. A neighbour sat in the front yard with a phone, working her way through a list of names, and the coffee pot was rumbling again.
As I left, I reflected on this little town, where isolation breeds a kind of practical connection between neighbours and among health care workers. No one lives more than 15 minutes away, and words are not wasted when there is soup to deliver or a prescription to pick up. Many of my patients list neighbours as their “next of kin” on hospital records; and as for the Home Care nurses — well, they know where I live, and they’ll deliver an internist to your kitchen table if they think she can be of assistance.
I arrived home from work to find my friend and trusted piano dealer in my living room, after he had spent 3 days on the road with the piano. The next challenge was to wrestle the piano into our inaccessible living room.
Then the cell phone rang. I wasn’t on call, but I smiled when I heard a familiar voice: “Hello, it’s Anna from Home Care. I’m so sorry to bother you, but I can’t reach the physicians who have been following one of our palliative patients …”
The family physician was in an outlying community, and the locum covering his practice first tried to send the patient to the ER and then could not be reached by phone. The palliative care “call group” in Yellowknife consists of myself, anytime, as long as I can be reached, precisely because of situations like these.
The patient, a young father of 3, was dying at home of a malignancy. He had just been started on some morphine for respiratory distress, but Anna felt he would benefit from a benzodiazepine as well. I couldn’t give her a phone order for a patient I’d never seen, but we arranged for a home visit the next day — my day off, but I would welcome another commitment around the time that my piano would be dangling from a crane in the front yard.
Next came the delicate task of soliciting a consult. I cannot advertise myself as a palliative care specialist, but most family physicians accept my involvement through Home Care during their own absences, or in the event that a homebound patient requires internal medicine services. Yellowknife’s Home Care nurses are the local experts in symptom management, and they can usually wrangle a consult when needed. In this case, the family physician was happy to oblige.
Arriving at the little house the next day, I found the door open and walked in to find Karen, another nurse, at the kitchen table. The patient’s young wife, wearing pyjamas and a bandana, had more dignity and grace about her than many a suit-clad business type.
She handed me a plate of waffles, pointed to the syrup, and continued her discussion of which medications were really needed at this point.
A middle-aged, cheerful fellow walked in just after me, carrying a large pot. “Beef barley,” he told the patient’s wife. “There’s space in the fridge,” she replied; he deposited the soup and left with a nod and a kind smile.
Between mouthfuls of waffles, I made some suggestions for medications, and phoned the pharmacist. I spoke with the patient, who awoke from a snooze on the couch to smile warmly at his wife and submit to a brief examination.
I didn’t need to know much; he had no pain, was scared but trusting, wanted to stay home until he died, and felt better with tiny doses of morphine and the occasional sleeping pill. I would come back on the weekend for another visit.
Before the next visit, I was called again — this time to declare the patient deceased and fill out the relevant paperwork.
The house was sad but peaceful, and his wife still wore her dignity and tenderness — perfectly paired with overalls and a t-shirt. A neighbour sat in the front yard with a phone, working her way through a list of names, and the coffee pot was rumbling again.
As I left, I reflected on this little town, where isolation breeds a kind of practical connection between neighbours and among health care workers. No one lives more than 15 minutes away, and words are not wasted when there is soup to deliver or a prescription to pick up. Many of my patients list neighbours as their “next of kin” on hospital records; and as for the Home Care nurses — well, they know where I live, and they’ll deliver an internist to your kitchen table if they think she can be of assistance.
Monday, June 30, 2008
Remote care by faxed flow chart
I arrive at work early on Monday to take care of some paperwork. A letter has been sitting on my desk for a week while I decide how to manage a cardiologist’s apparently simple request: to follow a patient’s hypertension after discharge from Edmonton.
After a left thalamic hemorrhage and a diagnosis of hypertensive cardiomyopathy (with an LVEF of 27%), the patient clearly needs frequent follow-up.
The cardiologist probably imagined me booking monthly clinic appointments, adjusting medications, and handing the patient a lab requisition each time. I guess he doesn’t have a map of the north in his clinic.
The patient is from a coastal community in Nunavut, 1100 km away with no road access. The cheapest return flight to Yellowknife, where I practice, costs over $1500. His community is intermittently served by a rotation of family physicians visiting for a week at a time; between physician visits, the nurse in charge runs the show.
I pick up my dictaphone and begin with the usual header: “Dear nurse in charge, I would be grateful for your help in following this patient who was referred to me by his Edmonton cardiologist for hypertension follow-up. Attached is a flow sheet that should be faxed to me every 2 weeks by your home care nurse. …”
After the dictation, I type up the flow chart. Every 2 weeks: blood pressure, heart rate, symptoms. Every 4 weeks: weight, creatinine, and potassium. Fax the form to my clinic and I will fax back necessary changes in medications. Call me with any concerns and book the patient to see the internist who visits his community every 6 months.
I add a postscript to my dictation: “I would like to see this patient when he comes down to Yellowknife for his next echocardiogram, which will be booked for the fall of this year.”
It will be a pleasure — even a luxury — to eventually meet the patient whose care I will be overseeing for the next several months, although I trust his community’s nursing team to contact me with any concerns in the meantime.
I must admit that I felt some trepidation the first time I managed a remote CHF patient by faxed flow sheet. But I have become accustomed to this model of care, and what is lost by the physician being off-site is often gained back by frequent nursing contact and the ability to find a patient easily in the small community.
Northern nurses are attuned to monitoring subtle clinical changes; perhaps because they will be the ones stuck managing pulmonary edema — alone — if the patient decompensates, with a medevac plane many hours away.
My favorite northern band, the Gumboots, wrote a song in honour of the average northern nurse: “…She’s an angel, she’s a surgeon, and she operates alone. Guided through the angioplasty by a doctor on the phone. …”
Poetic license and frontier hyperbole aside, I know my patient is in good hands.
It has taken me 45 minutes to organize his follow-up. Fortunately, I’m on salary. I wouldn’t know how to bill for a flow sheet anyway.
After a left thalamic hemorrhage and a diagnosis of hypertensive cardiomyopathy (with an LVEF of 27%), the patient clearly needs frequent follow-up.
The cardiologist probably imagined me booking monthly clinic appointments, adjusting medications, and handing the patient a lab requisition each time. I guess he doesn’t have a map of the north in his clinic.
The patient is from a coastal community in Nunavut, 1100 km away with no road access. The cheapest return flight to Yellowknife, where I practice, costs over $1500. His community is intermittently served by a rotation of family physicians visiting for a week at a time; between physician visits, the nurse in charge runs the show.
I pick up my dictaphone and begin with the usual header: “Dear nurse in charge, I would be grateful for your help in following this patient who was referred to me by his Edmonton cardiologist for hypertension follow-up. Attached is a flow sheet that should be faxed to me every 2 weeks by your home care nurse. …”
After the dictation, I type up the flow chart. Every 2 weeks: blood pressure, heart rate, symptoms. Every 4 weeks: weight, creatinine, and potassium. Fax the form to my clinic and I will fax back necessary changes in medications. Call me with any concerns and book the patient to see the internist who visits his community every 6 months.
I add a postscript to my dictation: “I would like to see this patient when he comes down to Yellowknife for his next echocardiogram, which will be booked for the fall of this year.”
It will be a pleasure — even a luxury — to eventually meet the patient whose care I will be overseeing for the next several months, although I trust his community’s nursing team to contact me with any concerns in the meantime.
I must admit that I felt some trepidation the first time I managed a remote CHF patient by faxed flow sheet. But I have become accustomed to this model of care, and what is lost by the physician being off-site is often gained back by frequent nursing contact and the ability to find a patient easily in the small community.
Northern nurses are attuned to monitoring subtle clinical changes; perhaps because they will be the ones stuck managing pulmonary edema — alone — if the patient decompensates, with a medevac plane many hours away.
My favorite northern band, the Gumboots, wrote a song in honour of the average northern nurse: “…She’s an angel, she’s a surgeon, and she operates alone. Guided through the angioplasty by a doctor on the phone. …”
Poetic license and frontier hyperbole aside, I know my patient is in good hands.
It has taken me 45 minutes to organize his follow-up. Fortunately, I’m on salary. I wouldn’t know how to bill for a flow sheet anyway.
Wednesday, June 18, 2008
Coming soon...Dr. Amy Hendricks
Starting at the beginning of July, Yellowknife physician and classical musician Dr. Amy Hendricks will be writing a "North of the 60th" blog which will cover the unique challenges involved in delivering medical care, often through interpreters, over the vast distances of the North.
Tuesday, April 29, 2008
Thank you, Dr. Sherk
Thus concludes the first CMAJ blog. Dr. Peter Sherk, a civilian internist and critical care specialist in Victoria, British Columbia, recently returned from a deployment to Kandahar, Afghanistan at the Multinational Medical Unit. We thank Dr. Sherk for his thoughtful submissions and hope that you enjoyed reading them. If you’re thirsting for more, we recommend reading similar accounts of life in Afghanistan by Dr. Sherk and others, in Outside the Wire: The War in Afghanistan in the Words of its Participants (Random House Canada; 2007).
Stay tuned for more CMAJ blogs.
Barbara Sibbald
Deputy Editor, News and Humanities
CMAJ
Stay tuned for more CMAJ blogs.
Barbara Sibbald
Deputy Editor, News and Humanities
CMAJ
Wednesday, April 16, 2008
“Muhibullah”
There are few things on earth faster moving than 4 stretcher bearers with a badly injured patient. First you hear the helicopter approaching, and then you feel the whirling and thumping in your chest. The Blackhawks whump down nimbly 200 yards from the back of the hospital whose plywood walls resonate in time with the rotor blades. A minute or 2 later the doors of the emergency room burst apart as a blur of medics stream in carrying the wounded, slowing only at the last second to carefully set down their precious cargo in the resuscitation bays.
You can kind of tell how sick the patient might be by first looking at the face of the medic. Sergeant Lopez (a pseudonym) had sprinted in to deliver a 5-year-old boy lying half-naked and crying under a pile of woollen army blankets. Lopez’ face was smeared with dust, sweat and worry. He watched intently as the trauma team assumed the next phase of the child’s care, knowing he had done everything possible and hoping it would be enough. Two hours ago this corpulent straight-talking US Army medic was riding south in a convoy through the Shahjoy district of Zabul province after many weeks “out in Taliban country huntin’ for bad guys.” He and his unit of 10 men were returning to KAF to resupply and were looking forward to a shower, a hot meal and a place to sleep softer than the floor of a Humvee.
As they entered a village, curious children approached the convoy thinking they might receive a piece of candy tossed from a vehicle’s turret. Lopez emphatically denies that his unit gives candy to children in this way. “The kids sometimes get way too close to the vehicles,” he tells me, and a Canadian soldier overhearing our conversation adds that the Canadian Forces stopped distributing candy from moving convoys during the Balkan conflict because the danger to the children. Unfortunately this morning one little boy ran in to the path of a Jingle truck, the driver of which had sped off without stopping. Jingle trucks get their name from the sound made by the chain tassels that hang down noisily from the trucks heavily reinforced front bumpers. The trucks are also usually decorated with garishly painted scenes or phrases. One of the trucks we see around camp displays a huge portrait of Benazir Bhutto along one side.
A huddle of villagers was gathering around the boy. Sergeant Lopez, who resembles a portly, more compact version of Rambo, halted the convoy and got out to examine the child lying crumpled at the roadside. After a year long deployment in Iraq, Lopez has the experienced medic’s ability to make critical triage decisions in the blink of an eye and knew immediately that he could help. He radioed for a Blackhawk helicopter to airlift the boy to medical attention.
As unusual as this may seem, the medics within the International Security Assistance Forces (ISAF) take something of a risk when they try to evacuate non-combat injured civilians to military hospitals. ISAF maintains 4 multinational medical units to cover the southwest region of Afghanistan. Priority of admission to these well-equipped, well-staffed hospitals is given first to injured coalition soldiers, second to injured Afghan security forces, and third to Afghan civilians. The medical air transport controllers are highly selective about which civilians can be admitted and it is nearly impossible for a civilian to gain admission without a strong advocate which in most cases is a medic. A recent example, recounted to me by Dr. Jack Oliver, an orthopedic surgeon from Kelowna, British Columbia, involved an emaciated 12-year-old boy with tuberculous vertebral osteomyelitis whose family had tried and failed to have admitted at the Kandahar Airfield (KAF) hospital until a medic intervened and saved his life. Surgeons at KAF stabilized his rotting spine and provided him with 6 months of antimycobacterial medication. Dr. Oliver sees him in follow up and cheerfully reports that the child is now thriving.
While Maj. Will Patton, the trauma team leader, and civilian Paul MacInnes, the lead nurse, work with the other staff to stabilize the child, Sergeant Lopez at last relaxes enough to remove his helmet and flak vest, then turns to the boy’s silent father and gives him a gentle reassuring squeeze on the shoulder. The compassion evinced by Lopez in this small gesture does not go unnoticed by Dr. Bob Ellett, our vascular surgeon who congratulates Lopez for the kindness he has shown. For only a brief moment, this reservist medic who is a youth worker in civilian life, allows himself to feel the pride he deserves to feel and closes his eyes to prevent several tears from falling.
The boys name is Muhibullah which means “God’s grace.” He has a large scalp hematoma overlying a long linear and comminuted skull fracture. He has a broken rib and a pulmonary contusion, but remarkably he has no immediately life threatening injury and several hours later he is calling out to his father that he wants to go home. Sergeant Lopez has not left Muhibullah’s side since bringing him in. We chat as I write up the admission orders. He shares with me some of the hardships of his army life: he lives in constant fear of driving over an IED. His 24th wedding anniversary passed yesterday and he was not able to call his wife back in the United States because he was out with his unit.
Why does Sergeant Lopez from upstate New York care so much about this injured child from one of the most impoverished areas of Afghanistan? Why did he marshal the full resources of the International Security and Assistance Force to aid a boy he had never met? I’m not sure. Why are people compassionate? There are theologians, evolutionary biologists and clinical psychologists who could provide interesting answers to that question, but because of his actions there may be a few villagers in Zabul who will feel that ISAF is here to offer real help to them when it is needed. And what is more, by demonstrating compassion today Sergeant Lopez is winning one of the hardest battles a soldier can fight — the fight to preserves one’s own humanity during war.
You can kind of tell how sick the patient might be by first looking at the face of the medic. Sergeant Lopez (a pseudonym) had sprinted in to deliver a 5-year-old boy lying half-naked and crying under a pile of woollen army blankets. Lopez’ face was smeared with dust, sweat and worry. He watched intently as the trauma team assumed the next phase of the child’s care, knowing he had done everything possible and hoping it would be enough. Two hours ago this corpulent straight-talking US Army medic was riding south in a convoy through the Shahjoy district of Zabul province after many weeks “out in Taliban country huntin’ for bad guys.” He and his unit of 10 men were returning to KAF to resupply and were looking forward to a shower, a hot meal and a place to sleep softer than the floor of a Humvee.
As they entered a village, curious children approached the convoy thinking they might receive a piece of candy tossed from a vehicle’s turret. Lopez emphatically denies that his unit gives candy to children in this way. “The kids sometimes get way too close to the vehicles,” he tells me, and a Canadian soldier overhearing our conversation adds that the Canadian Forces stopped distributing candy from moving convoys during the Balkan conflict because the danger to the children. Unfortunately this morning one little boy ran in to the path of a Jingle truck, the driver of which had sped off without stopping. Jingle trucks get their name from the sound made by the chain tassels that hang down noisily from the trucks heavily reinforced front bumpers. The trucks are also usually decorated with garishly painted scenes or phrases. One of the trucks we see around camp displays a huge portrait of Benazir Bhutto along one side.
A huddle of villagers was gathering around the boy. Sergeant Lopez, who resembles a portly, more compact version of Rambo, halted the convoy and got out to examine the child lying crumpled at the roadside. After a year long deployment in Iraq, Lopez has the experienced medic’s ability to make critical triage decisions in the blink of an eye and knew immediately that he could help. He radioed for a Blackhawk helicopter to airlift the boy to medical attention.
As unusual as this may seem, the medics within the International Security Assistance Forces (ISAF) take something of a risk when they try to evacuate non-combat injured civilians to military hospitals. ISAF maintains 4 multinational medical units to cover the southwest region of Afghanistan. Priority of admission to these well-equipped, well-staffed hospitals is given first to injured coalition soldiers, second to injured Afghan security forces, and third to Afghan civilians. The medical air transport controllers are highly selective about which civilians can be admitted and it is nearly impossible for a civilian to gain admission without a strong advocate which in most cases is a medic. A recent example, recounted to me by Dr. Jack Oliver, an orthopedic surgeon from Kelowna, British Columbia, involved an emaciated 12-year-old boy with tuberculous vertebral osteomyelitis whose family had tried and failed to have admitted at the Kandahar Airfield (KAF) hospital until a medic intervened and saved his life. Surgeons at KAF stabilized his rotting spine and provided him with 6 months of antimycobacterial medication. Dr. Oliver sees him in follow up and cheerfully reports that the child is now thriving.
While Maj. Will Patton, the trauma team leader, and civilian Paul MacInnes, the lead nurse, work with the other staff to stabilize the child, Sergeant Lopez at last relaxes enough to remove his helmet and flak vest, then turns to the boy’s silent father and gives him a gentle reassuring squeeze on the shoulder. The compassion evinced by Lopez in this small gesture does not go unnoticed by Dr. Bob Ellett, our vascular surgeon who congratulates Lopez for the kindness he has shown. For only a brief moment, this reservist medic who is a youth worker in civilian life, allows himself to feel the pride he deserves to feel and closes his eyes to prevent several tears from falling.
The boys name is Muhibullah which means “God’s grace.” He has a large scalp hematoma overlying a long linear and comminuted skull fracture. He has a broken rib and a pulmonary contusion, but remarkably he has no immediately life threatening injury and several hours later he is calling out to his father that he wants to go home. Sergeant Lopez has not left Muhibullah’s side since bringing him in. We chat as I write up the admission orders. He shares with me some of the hardships of his army life: he lives in constant fear of driving over an IED. His 24th wedding anniversary passed yesterday and he was not able to call his wife back in the United States because he was out with his unit.
Why does Sergeant Lopez from upstate New York care so much about this injured child from one of the most impoverished areas of Afghanistan? Why did he marshal the full resources of the International Security and Assistance Force to aid a boy he had never met? I’m not sure. Why are people compassionate? There are theologians, evolutionary biologists and clinical psychologists who could provide interesting answers to that question, but because of his actions there may be a few villagers in Zabul who will feel that ISAF is here to offer real help to them when it is needed. And what is more, by demonstrating compassion today Sergeant Lopez is winning one of the hardest battles a soldier can fight — the fight to preserves one’s own humanity during war.
Monday, April 14, 2008
“Stand by Ghost Rider!”
Strolling by the medical imaging console I find Dr. Daniel Lindsay, a radiologist from Winnipeg studying an abdominal CT scan. Only it doesn’t look like any abdomen I’ve ever seen before. The shape is smaller and more ovoid than I’m used to. The liver looks weird and the spleen is elongated and kind of wispy.
“We’ve got a dog in there with hemoperitoneum” he says with eyebrows raised pointing over his shoulder in the direction the scanner.
It’s a quiet morning and out of sheer curiosity I head in to the scanner. Sure enough, a furry black creature is sliding out of the gantry and the camp’s veterinarian Dr. Rance Erwin, a tall energetic US Army Captain is striding across the room with a syringe filled with blood that he has just withdrawn from his patient’s abdomen. “This looks bad. We’re gonna need t’get ‘im over to the vet tent rawt now” he says in the sonorous drawl of his native southern Kansas.
“What happened?” I ask addressing a man who is bending over the dog stroking its neck in silence.
“A Humvee hit him. We were playin’ ball and he ran out in front of the truck to get the ball. He saw it coming and tried to stop, so did the Humvee but there just wasn’t enough time…. The driver was an Afghan guy. He jumped out, seen what happened, froze for a second then took off.” He says this quietly, trying with difficulty to keep his emotions from surfacing.
“You’re his handler?” I ask.
He nods.
“How long have you guys worked together? I ask. “’Bout two years now. We were in Iraq. He’s been a good bomb sniffer, found lots of IEDs and saved my life a time or two,” he says to me never taking his eyes off the dog who lays muzzled and sedated, though not enough to take away the disconsolate look of a sentient creature in pain.
The dog’s name is Patrick. He’s a six year old Alsatian. The health and welfare of these animals is a very serious matter for the US army who regard them as soldiers, albeit of a different species.
Dr. Erwin heads out to prepare for his operation and I help to transfer the animal on to a purpose-made red plastic dog stretcher. While a vet assistant and I each take a corner at the front, the dog’s handler picks up the rear and we hurry out across the road to the vet tent.
When we arrive, the vet is already on the phone arranging for a canine blood donor. “Hi Sir, this is Captain Erwin over in the veterinary tent. We’ve got ourselves a little bit of a serious situation rawt now. We’ve got a military workin’ dog that was hit by a Humvee about two or three hours ago, and he’s got a lot of blood in his belly … Uh huh.... I’m not sure if it’s his spleen or what but I’m gonna have t’open im up and we’re gonna need some blood from another dog. I was wonderin’ if you can send over one of your dogs, one that has a nice-easy going personality ... Uh huh.... You have one that’s a little heavier, maybe 60 lbs or more? ... Sure, she’ll do fine. Thank you. Goodbye Sir.”
In one motion he hangs up the phone and leaps from his chair directing his assistants as he searches for a surgical mask and a pair of sterile gloves. “Stand by ghost rider!” he calls out which is loosely translated from US Armyspeak as “Help is on the way!” He then selects a bottle of isofluorane and begins to fill the vaporizing chamber on his anaesthetic machine. “Make sure you shave him way down. I’m gonna have to make a pretty long incision” he says as two assistants clipper the fur from the abdomen. “OK. Let’s get ‘im up on the table.”
Patrick, groggy from incipient hypovolemic shock and the canine sedative mixture of morphine, medetomadine and atropine, is limp as he is hoisted by three assistants in to a prone position on the stainless steel operating table. While this is going on, Capt. Erwin draws up a syringe of propofol and begins infusing it in to the IV taped in place on Patrick’s foreleg. Moments later, Patrick has drifted into unconsciousness and with the vet techs holding his jaws open and his long tongue off to one side, the Captain uses a strait bladed laryngoscope to pass an endotracheal tube in to position. Once the tube is secured, he is rolled supine. The surgeon pulls back the dog’s upper lip, assessing oxygenation and perfusion clinically by inspecting the colour of the gums and the tongue. Satisfied with what he sees, he sets himself to the next task: scrubbing his hands for surgery. Without the benefit of continuous electronic monitoring of tidal volume, cardiac rhythm, respiratory rate and oxygen saturation, Patrick will be breathe spontaneously for the operation, monitored at regular intervals by the veterinary technician who keeps watch on the pinkness of the tongue, the rate of his breathing, and by stethoscope, the soft “lub-dub-ing” of his heart.
Inexplicably, there is a lull in the action and with the exception of the Captain the others in the room find themselves at a loss for something to do.
“C’mon people, I see a lot of standin’ around let’s go!” says Capt. Erwin. “Let’s get this abdomen prepped. We’ve gotta speed up or this dog’s not going to make it.”
Snapping back to the situation at hand, one of the assistants begins with bare hands to soak 4X4’s of gauze in poviodine and swab them over the dog’s shaved, greyish-pink abdomen turning it a golden yellow colour and filling the warm tent with iodine’s distinctive thick, sour odour.
The Vet calls out for sterile drapes, abdominal sponges and laparotomy tray to be unpacked. He directs a tech to check the pulse.
“125, resp rate is 8 and his colour’s good” comes the reply.
“That’s fine, that’s fine” murmurs the surgeon.
“I think I’m gonna step outside for this part” says Patrick’s handler as Capt. Erwin steadies the scalpel for the first incision.
Dr. Lindsay enters the tent to give Capt. Erwin a full report of the CT. After carefully comparing the dog’s scan with his intimate knowledge of human structure, he has a serviceable understanding of canine abdominal anatomy. The spleen appears intact but the liver looks contused or lacerated — this news is not encouraging, for a splenic injury would certainly be the easiest to contend with.
Dr. Lindsay washes his hands and dons a pair of sterile gloves offering to assist Dr. Erwin. During the rather mechanical skin incision and dissection through the subcutaneous tissues to the peritoneal fascia there is a brief opportunity for small talk, and I learn that Dr. Erwin is an Army Reserve Vet, has been in practice for five years and is married to another vet. At home in the US, he divides his time between two private practices in Kansas.
“How long will you be here?” I ask.
“Six months it looks like. They’ve got it down to six. Use t’be 10 months y’know, but a lot of guys were losin’ their clinics back home ‘cos of those long deployments.”
Within minutes, Dr. Irwin’s fears and Dr. Lindsay’s predictions are confirmed: the spleen is fine. The liver looks quite beat up and to everyone’s surprise there is also a tear in the bladder. 375 ccs of blood have now been collected in the suction apparatus and the need for a blood transfusion is urgent.
My assignment during these events is to try and collect 120 cc of blood from another military dog that has just arrived outside. The donor’s name is Alaska and, rather ironically for a military dog, she is known for her good temperament. She also has an injury of her own. Her left front paw is bandaged up after losing part of it to an insurgent’s bullet that flew through the tailgate of the truck she was riding in. I am very apprehensive about trying to phlebotomize a wounded attack dog, even one in a muzzle with a reportedly good nature. Therefore, following Dr. Erwin’s orders the assistant steadies the hind leg of this docile canine soldier who under different circumstances is certainly capable of chilling ferocity. I inject a mixture of medetomidine and atropine in to the muscle and 10 minutes later the dog lies dozing at his handler’s feet. The vet tech has shaved and prepped the right foreleg and kindly shows me where to put the needle. I can’t find the vein. I try again. Still can’t get it. She tries unsuccessfully. She preps the right hind leg for a different vein, which we’re sure we can feel. We both try again but get back only a tiny trickle before we lose flow. Patrick’s handler is watching and offers to try but the veins elude him as well. I wonder if the dog is a little volume depleted from not drinking enough water in the hot Afghan sun as approximately 45 minutes has passed. I turn back to enter the tent to report that I’ve not been able to obtain the needed blood.
Walking through the door, I see Dr. Lindsay performing chest compressions while Dr. Erwin is delivering a dose of intracardiac epinephrine. CPR on a dog is performed by placing the hands on either side of the rib cage and pushing the sides together. I join in by bagging but Patrick’s tongue has turned to a deep purple, almost black. Dr. Erwin grabs a stethoscope with bloodied hands and listens. The heart is silent.
“I’m callin’ this,” says the veterinarian, fatigue and sadness clearly evident in his voice as he adds “Damn! He was lookin’ so good there for a while.”
Dr. Lindsay and I look at one another and are at a loss for words as we consider the surreal events that have lead a radiologist and an internist from Canada to be standing beside the lifeless body of an American Army dog. Dr. Erwin composes himself and leaves the tent to break the bad news to Patrick’s handler.
“We lost him” he says directly, extending a hand of condolence towards the handler.
“Are you fuckin’ serious?!” yells Patrick’s handler slumping to a bench and burying his face in his hands.
Dr. Lindsay and I also try to offer condolences to the handler but his thoughts are elsewhere. In the manner of those who are suddenly and unexpectedly bereaved he is all alone in a maelstrom of memory and regret.
“We’ve got a dog in there with hemoperitoneum” he says with eyebrows raised pointing over his shoulder in the direction the scanner.
It’s a quiet morning and out of sheer curiosity I head in to the scanner. Sure enough, a furry black creature is sliding out of the gantry and the camp’s veterinarian Dr. Rance Erwin, a tall energetic US Army Captain is striding across the room with a syringe filled with blood that he has just withdrawn from his patient’s abdomen. “This looks bad. We’re gonna need t’get ‘im over to the vet tent rawt now” he says in the sonorous drawl of his native southern Kansas.
“What happened?” I ask addressing a man who is bending over the dog stroking its neck in silence.
“A Humvee hit him. We were playin’ ball and he ran out in front of the truck to get the ball. He saw it coming and tried to stop, so did the Humvee but there just wasn’t enough time…. The driver was an Afghan guy. He jumped out, seen what happened, froze for a second then took off.” He says this quietly, trying with difficulty to keep his emotions from surfacing.
“You’re his handler?” I ask.
He nods.
“How long have you guys worked together? I ask. “’Bout two years now. We were in Iraq. He’s been a good bomb sniffer, found lots of IEDs and saved my life a time or two,” he says to me never taking his eyes off the dog who lays muzzled and sedated, though not enough to take away the disconsolate look of a sentient creature in pain.
The dog’s name is Patrick. He’s a six year old Alsatian. The health and welfare of these animals is a very serious matter for the US army who regard them as soldiers, albeit of a different species.
Dr. Erwin heads out to prepare for his operation and I help to transfer the animal on to a purpose-made red plastic dog stretcher. While a vet assistant and I each take a corner at the front, the dog’s handler picks up the rear and we hurry out across the road to the vet tent.
When we arrive, the vet is already on the phone arranging for a canine blood donor. “Hi Sir, this is Captain Erwin over in the veterinary tent. We’ve got ourselves a little bit of a serious situation rawt now. We’ve got a military workin’ dog that was hit by a Humvee about two or three hours ago, and he’s got a lot of blood in his belly … Uh huh.... I’m not sure if it’s his spleen or what but I’m gonna have t’open im up and we’re gonna need some blood from another dog. I was wonderin’ if you can send over one of your dogs, one that has a nice-easy going personality ... Uh huh.... You have one that’s a little heavier, maybe 60 lbs or more? ... Sure, she’ll do fine. Thank you. Goodbye Sir.”
In one motion he hangs up the phone and leaps from his chair directing his assistants as he searches for a surgical mask and a pair of sterile gloves. “Stand by ghost rider!” he calls out which is loosely translated from US Armyspeak as “Help is on the way!” He then selects a bottle of isofluorane and begins to fill the vaporizing chamber on his anaesthetic machine. “Make sure you shave him way down. I’m gonna have to make a pretty long incision” he says as two assistants clipper the fur from the abdomen. “OK. Let’s get ‘im up on the table.”
Patrick, groggy from incipient hypovolemic shock and the canine sedative mixture of morphine, medetomadine and atropine, is limp as he is hoisted by three assistants in to a prone position on the stainless steel operating table. While this is going on, Capt. Erwin draws up a syringe of propofol and begins infusing it in to the IV taped in place on Patrick’s foreleg. Moments later, Patrick has drifted into unconsciousness and with the vet techs holding his jaws open and his long tongue off to one side, the Captain uses a strait bladed laryngoscope to pass an endotracheal tube in to position. Once the tube is secured, he is rolled supine. The surgeon pulls back the dog’s upper lip, assessing oxygenation and perfusion clinically by inspecting the colour of the gums and the tongue. Satisfied with what he sees, he sets himself to the next task: scrubbing his hands for surgery. Without the benefit of continuous electronic monitoring of tidal volume, cardiac rhythm, respiratory rate and oxygen saturation, Patrick will be breathe spontaneously for the operation, monitored at regular intervals by the veterinary technician who keeps watch on the pinkness of the tongue, the rate of his breathing, and by stethoscope, the soft “lub-dub-ing” of his heart.
Inexplicably, there is a lull in the action and with the exception of the Captain the others in the room find themselves at a loss for something to do.
“C’mon people, I see a lot of standin’ around let’s go!” says Capt. Erwin. “Let’s get this abdomen prepped. We’ve gotta speed up or this dog’s not going to make it.”
Snapping back to the situation at hand, one of the assistants begins with bare hands to soak 4X4’s of gauze in poviodine and swab them over the dog’s shaved, greyish-pink abdomen turning it a golden yellow colour and filling the warm tent with iodine’s distinctive thick, sour odour.
The Vet calls out for sterile drapes, abdominal sponges and laparotomy tray to be unpacked. He directs a tech to check the pulse.
“125, resp rate is 8 and his colour’s good” comes the reply.
“That’s fine, that’s fine” murmurs the surgeon.
“I think I’m gonna step outside for this part” says Patrick’s handler as Capt. Erwin steadies the scalpel for the first incision.
Dr. Lindsay enters the tent to give Capt. Erwin a full report of the CT. After carefully comparing the dog’s scan with his intimate knowledge of human structure, he has a serviceable understanding of canine abdominal anatomy. The spleen appears intact but the liver looks contused or lacerated — this news is not encouraging, for a splenic injury would certainly be the easiest to contend with.
Dr. Lindsay washes his hands and dons a pair of sterile gloves offering to assist Dr. Erwin. During the rather mechanical skin incision and dissection through the subcutaneous tissues to the peritoneal fascia there is a brief opportunity for small talk, and I learn that Dr. Erwin is an Army Reserve Vet, has been in practice for five years and is married to another vet. At home in the US, he divides his time between two private practices in Kansas.
“How long will you be here?” I ask.
“Six months it looks like. They’ve got it down to six. Use t’be 10 months y’know, but a lot of guys were losin’ their clinics back home ‘cos of those long deployments.”
Within minutes, Dr. Irwin’s fears and Dr. Lindsay’s predictions are confirmed: the spleen is fine. The liver looks quite beat up and to everyone’s surprise there is also a tear in the bladder. 375 ccs of blood have now been collected in the suction apparatus and the need for a blood transfusion is urgent.
My assignment during these events is to try and collect 120 cc of blood from another military dog that has just arrived outside. The donor’s name is Alaska and, rather ironically for a military dog, she is known for her good temperament. She also has an injury of her own. Her left front paw is bandaged up after losing part of it to an insurgent’s bullet that flew through the tailgate of the truck she was riding in. I am very apprehensive about trying to phlebotomize a wounded attack dog, even one in a muzzle with a reportedly good nature. Therefore, following Dr. Erwin’s orders the assistant steadies the hind leg of this docile canine soldier who under different circumstances is certainly capable of chilling ferocity. I inject a mixture of medetomidine and atropine in to the muscle and 10 minutes later the dog lies dozing at his handler’s feet. The vet tech has shaved and prepped the right foreleg and kindly shows me where to put the needle. I can’t find the vein. I try again. Still can’t get it. She tries unsuccessfully. She preps the right hind leg for a different vein, which we’re sure we can feel. We both try again but get back only a tiny trickle before we lose flow. Patrick’s handler is watching and offers to try but the veins elude him as well. I wonder if the dog is a little volume depleted from not drinking enough water in the hot Afghan sun as approximately 45 minutes has passed. I turn back to enter the tent to report that I’ve not been able to obtain the needed blood.
Walking through the door, I see Dr. Lindsay performing chest compressions while Dr. Erwin is delivering a dose of intracardiac epinephrine. CPR on a dog is performed by placing the hands on either side of the rib cage and pushing the sides together. I join in by bagging but Patrick’s tongue has turned to a deep purple, almost black. Dr. Erwin grabs a stethoscope with bloodied hands and listens. The heart is silent.
“I’m callin’ this,” says the veterinarian, fatigue and sadness clearly evident in his voice as he adds “Damn! He was lookin’ so good there for a while.”
Dr. Lindsay and I look at one another and are at a loss for words as we consider the surreal events that have lead a radiologist and an internist from Canada to be standing beside the lifeless body of an American Army dog. Dr. Erwin composes himself and leaves the tent to break the bad news to Patrick’s handler.
“We lost him” he says directly, extending a hand of condolence towards the handler.
“Are you fuckin’ serious?!” yells Patrick’s handler slumping to a bench and burying his face in his hands.
Dr. Lindsay and I also try to offer condolences to the handler but his thoughts are elsewhere. In the manner of those who are suddenly and unexpectedly bereaved he is all alone in a maelstrom of memory and regret.
Thursday, April 3, 2008
CME in Afghanistan
This morning we went to visit the Kandahar Regional Military Hospital (KRMH). We had been invited to attend a weekly continuing medical education (CME) session for the doctors, nurses and technicians at the hospital, which serves members of the Afghan National Army (ANA). The hospital, although within the security perimeter of the Kandahar Airfield (KAF), is a 10 minute drive outside the main boundary of the camp.
I will not soon forget my ride there in a Bison armoured troop carrier. The security threat is deemed low and I am permitted by my wary military chaperones to ride with my head poking up through a hatch at the back of the Bison. Poking his head out of the hatch beside me is Capt. Marc Descoteaux an extremely likable emergency physician from the St. Jean, Quebec garrison who makes no attempt to hide his obvious excitement and pride at being a military physician on one of his first excursions beyond the main camp at KAF.
“I enrolled in the military specifically so I could deploy here to Afghanistan” he says grinning from behind his reflective ballistic eyewear.
This moment seems uniquely Canadian as we commiserate about the similar medical experiences and ethical end-of-life challenges we have had working in intensive care units back home. As a unilingual Anglophone I am a little envious of his perfect English accented in a musical Quebecois. We both have 8-year-old sons and it makes me happy to think that my son who is in French Immersion will one day be as comfortable in both official languages as Capt. Descoteaux. As we roll along through the outskirts of camp I ask him for his evaluation of public support within Quebec for Canada’s mission here.
For him the answer is very personal: “First I am a Canadian. Second I am a Quebecer. When I completed all my military training and received my commission many people came to me after the ceremony to say how much they support me and what Canada is doing here.”
His ardour for the mission here is so obvious that I sense he feels a little confined even here in KAF. “I really want to see what’s going on out there...” he trails off, looking out over the apocalyptic scene speeding past us.
Scattered all around lay the bombed out remnants of former neighbourhoods and commercial areas. One wrecked apartment block known as “the Russian village” is in fact still a home to a number of families despite the fact that it has no running water or reliable supply of electricity. That such conditions exist almost within site of KAFs diesel powered electrical generators leaves me feeling both angry and embarrassed.
Approaching the ANA camp’s perimeter we see a bone yard of old rusting Soviet tanks and rocket launchers, an unsettling reminder of only the latest unsuccessful attempt to forcibly pacify this virtually ungovernable frontier. The Bison disgorges us out on to the parking lot of the impressive, newly built hospital — a testament to the capacity the US Military is building with the fledgling ANA. The support is staggering. The US is spending 100 million dollars a year to construct a network of more than 120 hospitals and health care centres across Afghanistan to serve 80 000 Afghan army personnel and their dependants. A few weeks ago, this hospital received and triaged nearly half of the 100 casualties from a Taliban suicide attack in Kandahar city. Such capability would have been unthinkable a year or 2 ago.
The CME sessions were instigated in part by Canadian Col. Colin McKay, one of the previous Commanding Officers of the KAF hospital. The idea was to foster an educational partnership between our hospital and the KRMH with whom we often share patients. The leader of this outing is an American army major who has volunteered one morning a week to these CME sessions.
“We’ve finally convinced some of our Afghan medical friends to stop giving antibiotics for pain,” he tells me conspiratorially as we walk towards a comfortable conference room that is filling with eager, exclusively male Afghan health care workers.
During the visit, I learn more about the current state of medical and nursing education in Afghanistan from Col. Ed Fieg an emergency physician from Ohio who has been assigned to be a clinical mentor to the fledgling KRMH. Col. Fieg seems straight out a scene from M.A.S.H. with a gum-chewing, straight-talking swagger that conceals a fierce intelligence and genuine concern for the people of this country.
In 2001, the country had just over 4000 doctors and just over 4700 nurses. For its 32 million people Afghanistan has 8 medical schools each with different entrance requirements offering a 7 year curriculum with variable objectives and requirements for graduation. The medical training system has a dire shortage of qualified professors. Moreover, actual exposure to real patients in a clinical setting doesn’t take place until the final year. Consequently, most physicians here are essentially “textbook” doctors. Following graduation, doctors serve a 1 or 2 year rotating internship the quality of which depends entirely upon the dedication and competence of their mentors. The system is also marred by the fact that where a doctor’s reputation is concerned, age and political connections are of greater importance than actual clinical skill. In fact, says Col Fieg, younger physicians will defer judgment to elders even when the younger physician has more knowledge and training.
The state of nursing education is no better. Decades of war have left Afghanistan with a critical shortage of trained nurses. Training programs are unstandardized, varying in length from 2 months to 3 years. As with their medical counterparts, there is limited exposure to patients in nursing school. Nurses are poorly respected by the medical community and are regularly assigned to non-nursing roles such as patient registration clerks, librarians, logistics providers or cleaning staff. There are a lack of policies and procedures governing work hours, standards of care and scope of practice. Medication administration and other bedside activities are not considered to be essential duties of a ward nurse. Patient assessment skills are rudimentary and there is essentially no nursing documentation. Col. Fieg has witnessed only limited evidence of patient education, discharge planning or collaborative case management. Overnight staffing at the hospital is dangerously sparse.
Perhaps worst of all, the nursing profession is heavily male dominated in a culture with very conservative restrictions governing male-female interactions. Male nurses, perhaps considering such tasks unbecoming, are not keen to attend to the hygienic needs of their patients, almost all of whom are also men.
During a break, I chat with an American nurse anesthetist seconded to this hospital. Trying to impart her considerable knowledge to colleagues who are sometimes many years her senior, she feels a sense of exasperation. “They have read a lot and have some good factual knowledge but haven’t had enough clinical experience to correctly apply what they know from textbooks. Next week, I’m giving a talk on how to interpret vital signs because the other day we had a patient in shock who was tachycardic. I had to convince them to give fluids for the tachycardia rather than digoxin which they wanted to use to slow the pulse.”
The foregoing comments notwithstanding, attendance at the rounds is excellent, much better in fact than medical rounds at my own hospital back in Canada. To one side of the room sit the Americans and Canadians in their military dress with pistols holstered at their sides while along the opposite wall and around the conference table are 14 Afghans, most dressed in shalwar kameez and sandals. The topic today is chest trauma and, specifically, recognition of tension pneumothorax, needle decompression, chest tube insertion and management. There is excellent audience participation from both the NATO and Afghan staff. Laughter and learning occur in equal proportion and 3 hours later we pile back in to the Bison and head back to KAF.
Along the route home we see a few children walking along the roadside. I love how they smile and wave spontaneously. These children have so much to teach us about resilience and hope.
During the last few weeks, largely because of the commitment of Col. Fieg and Dr. Jack Oliver the Canadian civilian orthopedic surgeon, we have started to see signs of a more lasting collaboration between our hospital at KAF and the KRMH whose surgeons are now operating together with greater regularity. Today I spent time discussing our management at the bedside of a badly burned patient with 3 doctors from the KRMH who had come to visit for the morning. This is something new from last year when I was first here. Hopefully, this connection between NATO’s doctors and the ANA’s doctors will continue and eventually grow to include physicians from the local civilian hospital in Kandahar City.
I will not soon forget my ride there in a Bison armoured troop carrier. The security threat is deemed low and I am permitted by my wary military chaperones to ride with my head poking up through a hatch at the back of the Bison. Poking his head out of the hatch beside me is Capt. Marc Descoteaux an extremely likable emergency physician from the St. Jean, Quebec garrison who makes no attempt to hide his obvious excitement and pride at being a military physician on one of his first excursions beyond the main camp at KAF.
“I enrolled in the military specifically so I could deploy here to Afghanistan” he says grinning from behind his reflective ballistic eyewear.
This moment seems uniquely Canadian as we commiserate about the similar medical experiences and ethical end-of-life challenges we have had working in intensive care units back home. As a unilingual Anglophone I am a little envious of his perfect English accented in a musical Quebecois. We both have 8-year-old sons and it makes me happy to think that my son who is in French Immersion will one day be as comfortable in both official languages as Capt. Descoteaux. As we roll along through the outskirts of camp I ask him for his evaluation of public support within Quebec for Canada’s mission here.
For him the answer is very personal: “First I am a Canadian. Second I am a Quebecer. When I completed all my military training and received my commission many people came to me after the ceremony to say how much they support me and what Canada is doing here.”
His ardour for the mission here is so obvious that I sense he feels a little confined even here in KAF. “I really want to see what’s going on out there...” he trails off, looking out over the apocalyptic scene speeding past us.
Scattered all around lay the bombed out remnants of former neighbourhoods and commercial areas. One wrecked apartment block known as “the Russian village” is in fact still a home to a number of families despite the fact that it has no running water or reliable supply of electricity. That such conditions exist almost within site of KAFs diesel powered electrical generators leaves me feeling both angry and embarrassed.
Approaching the ANA camp’s perimeter we see a bone yard of old rusting Soviet tanks and rocket launchers, an unsettling reminder of only the latest unsuccessful attempt to forcibly pacify this virtually ungovernable frontier. The Bison disgorges us out on to the parking lot of the impressive, newly built hospital — a testament to the capacity the US Military is building with the fledgling ANA. The support is staggering. The US is spending 100 million dollars a year to construct a network of more than 120 hospitals and health care centres across Afghanistan to serve 80 000 Afghan army personnel and their dependants. A few weeks ago, this hospital received and triaged nearly half of the 100 casualties from a Taliban suicide attack in Kandahar city. Such capability would have been unthinkable a year or 2 ago.
The CME sessions were instigated in part by Canadian Col. Colin McKay, one of the previous Commanding Officers of the KAF hospital. The idea was to foster an educational partnership between our hospital and the KRMH with whom we often share patients. The leader of this outing is an American army major who has volunteered one morning a week to these CME sessions.
“We’ve finally convinced some of our Afghan medical friends to stop giving antibiotics for pain,” he tells me conspiratorially as we walk towards a comfortable conference room that is filling with eager, exclusively male Afghan health care workers.
During the visit, I learn more about the current state of medical and nursing education in Afghanistan from Col. Ed Fieg an emergency physician from Ohio who has been assigned to be a clinical mentor to the fledgling KRMH. Col. Fieg seems straight out a scene from M.A.S.H. with a gum-chewing, straight-talking swagger that conceals a fierce intelligence and genuine concern for the people of this country.
In 2001, the country had just over 4000 doctors and just over 4700 nurses. For its 32 million people Afghanistan has 8 medical schools each with different entrance requirements offering a 7 year curriculum with variable objectives and requirements for graduation. The medical training system has a dire shortage of qualified professors. Moreover, actual exposure to real patients in a clinical setting doesn’t take place until the final year. Consequently, most physicians here are essentially “textbook” doctors. Following graduation, doctors serve a 1 or 2 year rotating internship the quality of which depends entirely upon the dedication and competence of their mentors. The system is also marred by the fact that where a doctor’s reputation is concerned, age and political connections are of greater importance than actual clinical skill. In fact, says Col Fieg, younger physicians will defer judgment to elders even when the younger physician has more knowledge and training.
The state of nursing education is no better. Decades of war have left Afghanistan with a critical shortage of trained nurses. Training programs are unstandardized, varying in length from 2 months to 3 years. As with their medical counterparts, there is limited exposure to patients in nursing school. Nurses are poorly respected by the medical community and are regularly assigned to non-nursing roles such as patient registration clerks, librarians, logistics providers or cleaning staff. There are a lack of policies and procedures governing work hours, standards of care and scope of practice. Medication administration and other bedside activities are not considered to be essential duties of a ward nurse. Patient assessment skills are rudimentary and there is essentially no nursing documentation. Col. Fieg has witnessed only limited evidence of patient education, discharge planning or collaborative case management. Overnight staffing at the hospital is dangerously sparse.
Perhaps worst of all, the nursing profession is heavily male dominated in a culture with very conservative restrictions governing male-female interactions. Male nurses, perhaps considering such tasks unbecoming, are not keen to attend to the hygienic needs of their patients, almost all of whom are also men.
During a break, I chat with an American nurse anesthetist seconded to this hospital. Trying to impart her considerable knowledge to colleagues who are sometimes many years her senior, she feels a sense of exasperation. “They have read a lot and have some good factual knowledge but haven’t had enough clinical experience to correctly apply what they know from textbooks. Next week, I’m giving a talk on how to interpret vital signs because the other day we had a patient in shock who was tachycardic. I had to convince them to give fluids for the tachycardia rather than digoxin which they wanted to use to slow the pulse.”
The foregoing comments notwithstanding, attendance at the rounds is excellent, much better in fact than medical rounds at my own hospital back in Canada. To one side of the room sit the Americans and Canadians in their military dress with pistols holstered at their sides while along the opposite wall and around the conference table are 14 Afghans, most dressed in shalwar kameez and sandals. The topic today is chest trauma and, specifically, recognition of tension pneumothorax, needle decompression, chest tube insertion and management. There is excellent audience participation from both the NATO and Afghan staff. Laughter and learning occur in equal proportion and 3 hours later we pile back in to the Bison and head back to KAF.
Along the route home we see a few children walking along the roadside. I love how they smile and wave spontaneously. These children have so much to teach us about resilience and hope.
During the last few weeks, largely because of the commitment of Col. Fieg and Dr. Jack Oliver the Canadian civilian orthopedic surgeon, we have started to see signs of a more lasting collaboration between our hospital at KAF and the KRMH whose surgeons are now operating together with greater regularity. Today I spent time discussing our management at the bedside of a badly burned patient with 3 doctors from the KRMH who had come to visit for the morning. This is something new from last year when I was first here. Hopefully, this connection between NATO’s doctors and the ANA’s doctors will continue and eventually grow to include physicians from the local civilian hospital in Kandahar City.
Thursday, March 27, 2008
The Boy from Bastion
One of my patients is a 3 year old boy from Helmand, the next province over, who was taken by his father to the British Bastion Air Field Hospital after he inhaled a small bead. It was decided to send the child to the Kandahar Air Field Hospital to have the bead removed.
The little boy arrived by helicopter already intubated. Xrays showed the jelly-bean sized bead nestled menacingly in a bronchus on the right. The child was difficult to ventilate and needed to be bagged by hand for several hours by the ICU nurses. Details of events prior to his arrival were sketchy but it is clear that his airway was very threatened.
I have heard from various sources the agonizing story of how the bead was extracted . There being no pediatric trachs available, the child was tracheotomised with a pediatric endotracheal tube (ETT). The bead could not be coaxed from its position in the airway however, and they returned to the operating theatre the next day to replace the ETT with the smallest adult trach available, whittled down to fit the child. Brief, tense moments of optimism as the bead was manipulated ever closer to the tracheal orifice were repeatedly erased as each extraction attempt failed to hold it for those crucial final seconds needed to deliver it out in to the open.
Again and again it would slide away and with it, the hopes of those in the room. The team of doctors improvised as best they could with the available tools. One surgeon even cut a tiny piece of mesh from the lining of his jacket, forming it in to a little net with which to trap the nefarious round bit of glass.
According to one who was present, the difficulty of the situation was added to by having more people than necessary in the operating theatre — all offering well intentioned advice. This is actually one of the challenges of working together in a multinational medical partnership. Moreover, the surgeons and anesthetists did not know each other well making it harder to offer advice without seeming off-putting. At one point it became virtually impossible to oxygentate and ventilate the child. Several frantic minutes passed before bilateral pneumothoraces were discovered and relieved with needle decompression and chest tube insertion. An orthopedic surgeon proposed passing a suction catheter down under fluoroscopy. To this someone else added the suggestion of placing a needle through the trachea to prevent the bead from tumbling down once it had been lifted close enough to the proximal end of the airway.
And after several hours the bead was finally captured.
Now 10 days later on the ward, the boy often jerks rigidly into an opisthotonic posture, crying out as his muscles from his neck to his toes stiffen painfully beyond his control. And though his eyes are open he does not interact. He seems unaware of the string of bright red, star shaped Christmas lights that the nurses have strung along his bedrails. Gathered into his father’s arms this man and his little son regard each other uncomprehendingly.
Yesterday the American medical team held a barbeque for every one behind the hospital, outside a tent called “The Stand Easy” that opens out on to the airstrip. One of the nurses carried the little boy out to the party, holding him in his muscular arms allowing him to feel the warmth of the afternoon sun. Only a few hundred yards away war planes land thunderously and take off, screaming through a haze of dust and I watch this scene in which frailty exists next to unimaginable power and it leaves me not knowing what to think.
Epilogue to this story:
We started to make plans to discharge the child. I called an Afghan physician at Bost Hospital Lashkar Gah . He was willing to receive the child but he told me to be honest with the boy’s father about the prognosis. The doctor was concerned that the boy’s father not be disappointed with the civilian hospital if the outcome was not going to be good.
It was difficult to explain all this to the boy’s father. He was crushed to learn that his son might never be the same again. Through an interpreter he pleaded with me not to send him to a local hospital and vowed that if he ever had enough money, he would take the boy to Pakistan or India for treatment. The family lived a 5 hour car trip to the west of Kandahar. I asked him if he had been able to let the boy’s mother know what had become of their youngest child. He told me the Taliban had destroyed the cell phone tower in their town and the mother was not fully aware of the child’s situation.
This was a difficult moment for me. Knowing that in Canada extracting the bead would have taken just a few minutes in the hands of a pediatric surgeon with the right tools. Knowing that after an anoxic injury, improvements would be very slow and disappointingly incomplete. Everybody worried that without a supply of enteral nutrition to drip down the NG tube it might be nearly impossible to feed the child enough. And we knew that there was no where else to send him but to the Afghan hospital closer to his home.
Several days later I called the physician at Bost Hospital to find out how the boy was doing. He told me that predictably, after 2 days the father had become impatient with the evidently stagnant neurological recovery and the hospital’s insufficient resources and taken the child home against the doctor’s advice.
If bleak reality is your cup of tea, I refer you to the website of the Senlis Council. Take a look at a report entitled War Zone Hospitals in Afghanistan: A Symbol of Wilful Neglect. The report contains photographs and clinical vignettes from the Bost Hospital where we sent the boy.
The little boy arrived by helicopter already intubated. Xrays showed the jelly-bean sized bead nestled menacingly in a bronchus on the right. The child was difficult to ventilate and needed to be bagged by hand for several hours by the ICU nurses. Details of events prior to his arrival were sketchy but it is clear that his airway was very threatened.
I have heard from various sources the agonizing story of how the bead was extracted . There being no pediatric trachs available, the child was tracheotomised with a pediatric endotracheal tube (ETT). The bead could not be coaxed from its position in the airway however, and they returned to the operating theatre the next day to replace the ETT with the smallest adult trach available, whittled down to fit the child. Brief, tense moments of optimism as the bead was manipulated ever closer to the tracheal orifice were repeatedly erased as each extraction attempt failed to hold it for those crucial final seconds needed to deliver it out in to the open.
Again and again it would slide away and with it, the hopes of those in the room. The team of doctors improvised as best they could with the available tools. One surgeon even cut a tiny piece of mesh from the lining of his jacket, forming it in to a little net with which to trap the nefarious round bit of glass.
According to one who was present, the difficulty of the situation was added to by having more people than necessary in the operating theatre — all offering well intentioned advice. This is actually one of the challenges of working together in a multinational medical partnership. Moreover, the surgeons and anesthetists did not know each other well making it harder to offer advice without seeming off-putting. At one point it became virtually impossible to oxygentate and ventilate the child. Several frantic minutes passed before bilateral pneumothoraces were discovered and relieved with needle decompression and chest tube insertion. An orthopedic surgeon proposed passing a suction catheter down under fluoroscopy. To this someone else added the suggestion of placing a needle through the trachea to prevent the bead from tumbling down once it had been lifted close enough to the proximal end of the airway.
And after several hours the bead was finally captured.
Now 10 days later on the ward, the boy often jerks rigidly into an opisthotonic posture, crying out as his muscles from his neck to his toes stiffen painfully beyond his control. And though his eyes are open he does not interact. He seems unaware of the string of bright red, star shaped Christmas lights that the nurses have strung along his bedrails. Gathered into his father’s arms this man and his little son regard each other uncomprehendingly.
Yesterday the American medical team held a barbeque for every one behind the hospital, outside a tent called “The Stand Easy” that opens out on to the airstrip. One of the nurses carried the little boy out to the party, holding him in his muscular arms allowing him to feel the warmth of the afternoon sun. Only a few hundred yards away war planes land thunderously and take off, screaming through a haze of dust and I watch this scene in which frailty exists next to unimaginable power and it leaves me not knowing what to think.
Epilogue to this story:
We started to make plans to discharge the child. I called an Afghan physician at Bost Hospital Lashkar Gah . He was willing to receive the child but he told me to be honest with the boy’s father about the prognosis. The doctor was concerned that the boy’s father not be disappointed with the civilian hospital if the outcome was not going to be good.
It was difficult to explain all this to the boy’s father. He was crushed to learn that his son might never be the same again. Through an interpreter he pleaded with me not to send him to a local hospital and vowed that if he ever had enough money, he would take the boy to Pakistan or India for treatment. The family lived a 5 hour car trip to the west of Kandahar. I asked him if he had been able to let the boy’s mother know what had become of their youngest child. He told me the Taliban had destroyed the cell phone tower in their town and the mother was not fully aware of the child’s situation.
This was a difficult moment for me. Knowing that in Canada extracting the bead would have taken just a few minutes in the hands of a pediatric surgeon with the right tools. Knowing that after an anoxic injury, improvements would be very slow and disappointingly incomplete. Everybody worried that without a supply of enteral nutrition to drip down the NG tube it might be nearly impossible to feed the child enough. And we knew that there was no where else to send him but to the Afghan hospital closer to his home.
Several days later I called the physician at Bost Hospital to find out how the boy was doing. He told me that predictably, after 2 days the father had become impatient with the evidently stagnant neurological recovery and the hospital’s insufficient resources and taken the child home against the doctor’s advice.
If bleak reality is your cup of tea, I refer you to the website of the Senlis Council. Take a look at a report entitled War Zone Hospitals in Afghanistan: A Symbol of Wilful Neglect. The report contains photographs and clinical vignettes from the Bost Hospital where we sent the boy.
Thursday, March 20, 2008
To Kandahar Airfield
At Canada’s forward logistics base near Afghanistan, flags fly at half mast for Trooper Mike Hayakaze, killed by an IED Mar. 2, 2008 near Kandahdar, the 80th Canadian to lose his life in Afghanistan. The flags of Canada, New Zealand, Australia, NATO and the base’s Host Nation flutter in the late afternoon breeze beside a grey granite memorial to all of Canada’s fallen soldiers. One can not help noticing that there is a great deal of empty space on the memorial and it must give pause to every soldier who pays his or her respects at this site to think that their name may be the next on the wall. Behind the memorial are three, 6 by 8 foot patches of arguably the best manicured lawn in Islamdom. Signs invite visitors to walk on them but no one does because their lushness seems too miraculous in this arid country to trample under foot.
The base is a way-station for Canada’s war in Afghanistan. Everybody and everything that is travelling to or from Kandahar Airfield (KAF) passes through this place at some point. Its location is officially classified, although it is actually something of an open secret. Signs every where on the base remind visitors that photography is strictly verboten. In some ways the place has the feel of a summer camp. Each barrack has been given a distinctively Canadian name like Hell’s Gate Lodge (British Columbia) and Joe Batt’s Arm Lodge (Newfoundland). And although the base swarms with soldiers and supplies between troop rotations, it is otherwise an almost torpid, sparsely peopled place where time seems at a standstill. Guardhouses are staffed by two people even though, during my three visits thus far, I didn’t think there was enough work for one. The mess hall, which is open 24 hours a day, has two large screen TVs, one in English and the other in French blaring the day’s newsbytes and hockey highlights in an endless cycle. Mealtimes are easygoing affairs that begin with a large helping of mashed carbohydrate thrust abruptly on to your plate by an industrial-sized spoon attached to the beefy arm of a matronly Australian army cook. Assisting her are half-a-dozen fine-boned Indian men adorned in blue chef’s frocks and white paper serving hats who, thank Allah, add tastier items like tandoori chicken or vegetable curry to your meal.
Outside, behind the basketball court, is the ball hockey rink, behind which is a soccer pitch, where I watched barefooted members of the host nation’s army playing the beautiful game early one morning. It gets much too hot to play later in the day.
There is also a barber shop and a poorly stocked library and a little building that is used as a music studio. Peering in the window to investigate the sounds coming from within, I saw an off-duty soldier alone with his electric guitar in a reverie of the Blues.
The day I am to leave for KAF I pick up my PPE (army-speak for personal protective equipment) which consists of helmet and flack jacket and although I feel goofy wearing it I am grateful for the protection it offers. Last year I had to wear it during two rocket attacks on KAF. I spend awhile reluctantly reading about burns and hemorrhagic shock in children, which are the scenarios I am most afraid to encounter. I review and commit to memory the outward indicators of thermal airway injury and the approach to fluid resuscitation in children. Then it is time for a work-out. Entering the nearly empty gym I sally over to a machine that promises to bulk up my long neglected pectoral and trapezius muscles. Thank God no one is looking I think for most of the next hour. At lunch I find my work-out has done me no good when I am thrown forward and off balance while trying to slide open a refrigerator door to get at the chocolate milk inside. Perhaps if I lack the fitness to open the refrigerator I shouldn’t be eating what’s inside?
That night at about 10 pm, those of us heading to KAF don our PPE and stand out on the tarmac behind 40 soldiers who have just flown in from Canada and have had all of an hour to stretch their legs before getting on the next C17 Globemaster flight to Kandahar.
In stark contrast to the heat of the day the nights are still very cold at this time of year. The role is called.
“Civilian Sherk!?” cries the Lieutenant.
“Here Sir!” I croak from the back.
The last duty before climbing aboard is for the soldiers to clear their weapons. Each soldier must present his or her gun for inspection, open the bullet chamber showing it to be empty and then pull the trigger while pointing in to a barrel of sand. My travelling companion this night is a fascinating man who works for the Canadian Department of Foreign Affairs. He is returning to KAF from Sarajevo where he spent his two week leave visiting with his daughter and wife. He has spent the last 10 months or so living in Kandahar City with the Provincial Reconstruction Team.
Here I think is a man who must know as much as anybody about Canada’s efforts in Afghanistan. He is very obliging with me but I sense he is more than a little weary of my sort of questions.
Progress is almost imperceptibly slow he agrees, while explaining that rebuilding Afghanistan is a task measured in decades or generations rather than months and Canadian election cycles. The security situation in Kandahar is very tenuous. And he knows whereof he speaks; he was a close acquaintance of Glyn Berry the Canadian diplomat killed by the Taliban in January 2006. He expresses, in the most restrained and diplomatic terms, the apoplectic frustration that Canada feels with other nations who will not make a commitment of troops to secure Kandahar province
“We’ll probably pull out if we don’t get some help” he predicts.
He has an unvarnished disdain for the Senlis Council who delivered an unflattering report on the efforts of the Canadian International Development Agency (CIDA) in Kandahar. He also disagrees with their assessment regarding conditions at the Mirwais hospital — the only civilian hospital in the province.
“CIDA had another consultant — I think a physician from Queen’s University -review the hospital and it’s nowhere near as bad as they [Senlis] say it is” he tells me, although he admits he has only been there once on a brief visit. He takes a pragmatic view of Senlis’ recommendation that Western nations should purchase the opium crop and turn it in to medical morphine.
“It will never happen. The Americans will never go for it” he says bluntly adding that Canadian soldiers are not actively involved in poppy eradication.
Finally I ask him to confirm a report I read in the Victoria Times-Colonist several days before I left Canada. It was stated that Kandahar city receives only 3 to 6 hours of electricity per day. I was astonished by this for two reasons. First, electricity flows in an almost obscene supply at KAF which is only kilometers from downtown Kandahar. And second, we’ve been trying to “stabilize and rebuild” Afghanistan since 2001 and after seven years one of the country’s main cities has only a few hours of electricity per day?! I was incredulous.
He explains that the Kajaki dam in neighbouring Helmand province was built to house three turbines. In three decades of war the dam has had next to no maintenance. Of late it has only had two turbines and one of them broke several months ago leaving just one to supply the region with power. There is a brand new turbine waiting to be moved to the dam, but repairs and renovations on the dam proceed at a glacial pace because of how badly the country’s infrastructure has been damaged by ceaseless war.
High above southern Afghanistan the lights along the cargo hold of the C17 change from green to red and we prepare for the plane’s descent. A tactical landing is a stomach churning manoeuvre in which the plane dives down sharply toward the landing strip rather than following the long slow descent more familiar to commercial aircraft. This is done to make the plane a more difficult target for anyone attempting to shoot it down. Trying to hold on to my supper as I feel my stomach rising to my throat, I watch in amazement as some of the soldiers throw their hands in the air the way riders on a roller coaster do. I guess you have to find entertainment wherever you can get it!
The muscular whine of the C17s engines recedes behind me as I cross the windblown tarmac, taking in the familiar surroundings without really watching where I’m going. I see they’ve finally condemned the old Soviet era hanger whose roof contained more mortar and bullet holes than actual metal and which always made quite an impression upon new visitors in case they had any doubts that they were in a war zone.
“Dr. Sherk?” says a man dressed in desert fatigues who I had not noticed standing beside me.
He looks a little like William Osler in battle dress. This is the Armed Forces’ Chief Internist, Col. Neil Gibson, a man who has a friendly, reassuring face, carries himself in an upright, capable manner and says what he’s thinking with an economy of words. Despite the late hour and an unpleasant cold brought on by being on-call continuously for two months, Col. Gibson is kind enough to carry some of my luggage to a borrowed Toyota 4X4 so choked with dust that the only way in is through the front passenger door. He helps me to my accommodations where feeling both excitement and apprehension after my travels, I crash in to a dreamless sleep.
The base is a way-station for Canada’s war in Afghanistan. Everybody and everything that is travelling to or from Kandahar Airfield (KAF) passes through this place at some point. Its location is officially classified, although it is actually something of an open secret. Signs every where on the base remind visitors that photography is strictly verboten. In some ways the place has the feel of a summer camp. Each barrack has been given a distinctively Canadian name like Hell’s Gate Lodge (British Columbia) and Joe Batt’s Arm Lodge (Newfoundland). And although the base swarms with soldiers and supplies between troop rotations, it is otherwise an almost torpid, sparsely peopled place where time seems at a standstill. Guardhouses are staffed by two people even though, during my three visits thus far, I didn’t think there was enough work for one. The mess hall, which is open 24 hours a day, has two large screen TVs, one in English and the other in French blaring the day’s newsbytes and hockey highlights in an endless cycle. Mealtimes are easygoing affairs that begin with a large helping of mashed carbohydrate thrust abruptly on to your plate by an industrial-sized spoon attached to the beefy arm of a matronly Australian army cook. Assisting her are half-a-dozen fine-boned Indian men adorned in blue chef’s frocks and white paper serving hats who, thank Allah, add tastier items like tandoori chicken or vegetable curry to your meal.
Outside, behind the basketball court, is the ball hockey rink, behind which is a soccer pitch, where I watched barefooted members of the host nation’s army playing the beautiful game early one morning. It gets much too hot to play later in the day.
There is also a barber shop and a poorly stocked library and a little building that is used as a music studio. Peering in the window to investigate the sounds coming from within, I saw an off-duty soldier alone with his electric guitar in a reverie of the Blues.
The day I am to leave for KAF I pick up my PPE (army-speak for personal protective equipment) which consists of helmet and flack jacket and although I feel goofy wearing it I am grateful for the protection it offers. Last year I had to wear it during two rocket attacks on KAF. I spend awhile reluctantly reading about burns and hemorrhagic shock in children, which are the scenarios I am most afraid to encounter. I review and commit to memory the outward indicators of thermal airway injury and the approach to fluid resuscitation in children. Then it is time for a work-out. Entering the nearly empty gym I sally over to a machine that promises to bulk up my long neglected pectoral and trapezius muscles. Thank God no one is looking I think for most of the next hour. At lunch I find my work-out has done me no good when I am thrown forward and off balance while trying to slide open a refrigerator door to get at the chocolate milk inside. Perhaps if I lack the fitness to open the refrigerator I shouldn’t be eating what’s inside?
That night at about 10 pm, those of us heading to KAF don our PPE and stand out on the tarmac behind 40 soldiers who have just flown in from Canada and have had all of an hour to stretch their legs before getting on the next C17 Globemaster flight to Kandahar.
In stark contrast to the heat of the day the nights are still very cold at this time of year. The role is called.
“Civilian Sherk!?” cries the Lieutenant.
“Here Sir!” I croak from the back.
The last duty before climbing aboard is for the soldiers to clear their weapons. Each soldier must present his or her gun for inspection, open the bullet chamber showing it to be empty and then pull the trigger while pointing in to a barrel of sand. My travelling companion this night is a fascinating man who works for the Canadian Department of Foreign Affairs. He is returning to KAF from Sarajevo where he spent his two week leave visiting with his daughter and wife. He has spent the last 10 months or so living in Kandahar City with the Provincial Reconstruction Team.
Here I think is a man who must know as much as anybody about Canada’s efforts in Afghanistan. He is very obliging with me but I sense he is more than a little weary of my sort of questions.
Progress is almost imperceptibly slow he agrees, while explaining that rebuilding Afghanistan is a task measured in decades or generations rather than months and Canadian election cycles. The security situation in Kandahar is very tenuous. And he knows whereof he speaks; he was a close acquaintance of Glyn Berry the Canadian diplomat killed by the Taliban in January 2006. He expresses, in the most restrained and diplomatic terms, the apoplectic frustration that Canada feels with other nations who will not make a commitment of troops to secure Kandahar province
“We’ll probably pull out if we don’t get some help” he predicts.
He has an unvarnished disdain for the Senlis Council who delivered an unflattering report on the efforts of the Canadian International Development Agency (CIDA) in Kandahar. He also disagrees with their assessment regarding conditions at the Mirwais hospital — the only civilian hospital in the province.
“CIDA had another consultant — I think a physician from Queen’s University -review the hospital and it’s nowhere near as bad as they [Senlis] say it is” he tells me, although he admits he has only been there once on a brief visit. He takes a pragmatic view of Senlis’ recommendation that Western nations should purchase the opium crop and turn it in to medical morphine.
“It will never happen. The Americans will never go for it” he says bluntly adding that Canadian soldiers are not actively involved in poppy eradication.
Finally I ask him to confirm a report I read in the Victoria Times-Colonist several days before I left Canada. It was stated that Kandahar city receives only 3 to 6 hours of electricity per day. I was astonished by this for two reasons. First, electricity flows in an almost obscene supply at KAF which is only kilometers from downtown Kandahar. And second, we’ve been trying to “stabilize and rebuild” Afghanistan since 2001 and after seven years one of the country’s main cities has only a few hours of electricity per day?! I was incredulous.
He explains that the Kajaki dam in neighbouring Helmand province was built to house three turbines. In three decades of war the dam has had next to no maintenance. Of late it has only had two turbines and one of them broke several months ago leaving just one to supply the region with power. There is a brand new turbine waiting to be moved to the dam, but repairs and renovations on the dam proceed at a glacial pace because of how badly the country’s infrastructure has been damaged by ceaseless war.
High above southern Afghanistan the lights along the cargo hold of the C17 change from green to red and we prepare for the plane’s descent. A tactical landing is a stomach churning manoeuvre in which the plane dives down sharply toward the landing strip rather than following the long slow descent more familiar to commercial aircraft. This is done to make the plane a more difficult target for anyone attempting to shoot it down. Trying to hold on to my supper as I feel my stomach rising to my throat, I watch in amazement as some of the soldiers throw their hands in the air the way riders on a roller coaster do. I guess you have to find entertainment wherever you can get it!
The muscular whine of the C17s engines recedes behind me as I cross the windblown tarmac, taking in the familiar surroundings without really watching where I’m going. I see they’ve finally condemned the old Soviet era hanger whose roof contained more mortar and bullet holes than actual metal and which always made quite an impression upon new visitors in case they had any doubts that they were in a war zone.
“Dr. Sherk?” says a man dressed in desert fatigues who I had not noticed standing beside me.
He looks a little like William Osler in battle dress. This is the Armed Forces’ Chief Internist, Col. Neil Gibson, a man who has a friendly, reassuring face, carries himself in an upright, capable manner and says what he’s thinking with an economy of words. Despite the late hour and an unpleasant cold brought on by being on-call continuously for two months, Col. Gibson is kind enough to carry some of my luggage to a borrowed Toyota 4X4 so choked with dust that the only way in is through the front passenger door. He helps me to my accommodations where feeling both excitement and apprehension after my travels, I crash in to a dreamless sleep.
Wednesday, March 19, 2008
The Power of Audacity
My war begins in luxury. Those in Ottawa who decide such things have deemed that I shall fly to Afghanistan for my 5-week locum in business class. The rationale for this I am told, is that if I arrive well rested I will be all the more ready to assume my duties with a clear head, a stout heart and a steady hand. Though a year ago when I came, I travelled mostly on red-eye Canadian Forces cargo service flights and still managed to arrive feeling pretty good. What has changed I wonder in the last year? Has a civilian internist-intensivist become such an indispensible military asset that no expense should be spared in assuring him a pleasant trip? The logic that the doctor should fly business class so that the soldier won’t fly home in a coffin seems weak at best — to me anyway.
The full Colonel I am going to replace, a dedicated physician from Edmonton who began his career as a pipe-fitter, who has stayed with the Forces through good times and bad, and who has completed 3 tours in Afghanistan totaling many months, arrived here and will fly home in economy class.
I think I’m good at my job and that what I have to contribute is important. But in the grand scheme I don’t think it is more important than role of the brave medics who risk their necks “outside the wire” at forward operating bases and on battlefields across Kandahar province. In fact, 4 Canadian medics have been killed in the last 2 years here. Pictures of CplC Christian Duchesne (34) and Cpls Glen Arnold (32), Nicholas Beauchamp (28) and Andrew Eykelenboom (23) look down from a wall in the entrance to the hospital.
I have never flown anywhere in such style and I am befuddled by the array of buttons that controls my seat. Evidently I am too short for business class — a roller in the seatback, meant to gently massage my lumbar lordosis is instead crushing my mid-thoracic kyphosis and it is several panic stricken minutes before I find the button that brings this chiropractic manipulation to an end. Next to me on the flight sits a man whom I will resemble in 20 years, unless I am careful to eat properly and exercise regularly. Like a virtuoso pianist attacking the faster bits of a Rachmaninoff concerto he taps a Blackberry that matches the dark sheen of his expensive looking clothes. Interrupting his e-mail cadenza he smiles and asks in a friendly manner where I’m going.
“Afghanistan” I say. “I’m going to work on the Kandahdar Airfield for a few weeks.”
“What are you going to do there?” he says, looking a little puzzled after my unexpected response.
“I’m a doctor. I’m going to look after wounded people in the base’s hospital.”
“Are you a GP?”
People always ask that question, I’m never sure why.
“No, I specialize in intensive care. Right now, the military doesn’t have quite enough doctors who do my sort of work so they fill in the gaps with civilians like me.”
I have found that there are several common responses when people find out that I’m going on this trip. Some assume (wrongly) that it is quite exotic or dangerous on the Kandahar Airfield and that I must be a little crazy or very brave, or both. Others seem impressed at what they perceive (in part correctly) to be an act of patriotic or humanitarian commitment. Another kind of person wearily opines that the whole war is a quagmire, all the papers say so, and it may true that the Taliban are beastly, but nobody ever has, nor ever will bring “that country” under external control. Last are the people who, like my travelling companion really don’t know what to say next. Notions of war and wounded people seem thoroughly at odds with our immediate surroundings and the juxtaposition brings our conversation awkwardly to a halt until I venture to ask him what line of work he is in.
“Shopping Malls” he says brightening. “I plan them.”
“That must be very interesting,” I observe, thinking exactly the opposite.
“And where are you headed to plan these shopping malls?”
“Moscow and then India.”
I mention that my trip will take me through a city that is well known as a shopping destination.
“Yes, that place is really something, you’re going to love it,” he says with a hint of jealousy that he can’t go too. “I just attended a seminar last week about the Power of Audacity! That’s what that place is really all about.”
Adjusting my chair in to a reclining position, I feel tired but can’t sleep. I shift uncomfortably, filled with a sense of unease at being a person of privilege in this world of wars and audacious shopping malls. I think about the patients, mostly members of the Afghan security forces and wounded civilians, who within hours will be under my care, and about the global disparity between poor and rich, which is itself a form of violence.
The full Colonel I am going to replace, a dedicated physician from Edmonton who began his career as a pipe-fitter, who has stayed with the Forces through good times and bad, and who has completed 3 tours in Afghanistan totaling many months, arrived here and will fly home in economy class.
I think I’m good at my job and that what I have to contribute is important. But in the grand scheme I don’t think it is more important than role of the brave medics who risk their necks “outside the wire” at forward operating bases and on battlefields across Kandahar province. In fact, 4 Canadian medics have been killed in the last 2 years here. Pictures of CplC Christian Duchesne (34) and Cpls Glen Arnold (32), Nicholas Beauchamp (28) and Andrew Eykelenboom (23) look down from a wall in the entrance to the hospital.
I have never flown anywhere in such style and I am befuddled by the array of buttons that controls my seat. Evidently I am too short for business class — a roller in the seatback, meant to gently massage my lumbar lordosis is instead crushing my mid-thoracic kyphosis and it is several panic stricken minutes before I find the button that brings this chiropractic manipulation to an end. Next to me on the flight sits a man whom I will resemble in 20 years, unless I am careful to eat properly and exercise regularly. Like a virtuoso pianist attacking the faster bits of a Rachmaninoff concerto he taps a Blackberry that matches the dark sheen of his expensive looking clothes. Interrupting his e-mail cadenza he smiles and asks in a friendly manner where I’m going.
“Afghanistan” I say. “I’m going to work on the Kandahdar Airfield for a few weeks.”
“What are you going to do there?” he says, looking a little puzzled after my unexpected response.
“I’m a doctor. I’m going to look after wounded people in the base’s hospital.”
“Are you a GP?”
People always ask that question, I’m never sure why.
“No, I specialize in intensive care. Right now, the military doesn’t have quite enough doctors who do my sort of work so they fill in the gaps with civilians like me.”
I have found that there are several common responses when people find out that I’m going on this trip. Some assume (wrongly) that it is quite exotic or dangerous on the Kandahar Airfield and that I must be a little crazy or very brave, or both. Others seem impressed at what they perceive (in part correctly) to be an act of patriotic or humanitarian commitment. Another kind of person wearily opines that the whole war is a quagmire, all the papers say so, and it may true that the Taliban are beastly, but nobody ever has, nor ever will bring “that country” under external control. Last are the people who, like my travelling companion really don’t know what to say next. Notions of war and wounded people seem thoroughly at odds with our immediate surroundings and the juxtaposition brings our conversation awkwardly to a halt until I venture to ask him what line of work he is in.
“Shopping Malls” he says brightening. “I plan them.”
“That must be very interesting,” I observe, thinking exactly the opposite.
“And where are you headed to plan these shopping malls?”
“Moscow and then India.”
I mention that my trip will take me through a city that is well known as a shopping destination.
“Yes, that place is really something, you’re going to love it,” he says with a hint of jealousy that he can’t go too. “I just attended a seminar last week about the Power of Audacity! That’s what that place is really all about.”
Adjusting my chair in to a reclining position, I feel tired but can’t sleep. I shift uncomfortably, filled with a sense of unease at being a person of privilege in this world of wars and audacious shopping malls. I think about the patients, mostly members of the Afghan security forces and wounded civilians, who within hours will be under my care, and about the global disparity between poor and rich, which is itself a form of violence.
Monday, March 17, 2008
Welcome to my blog from Kandahar
Hello and welcome to my blog. I am presently on the Kandahar Airfield (KAF), which is a 40 minute drive outside of Kandahar City in Afghanistan. Some time before I left Canada, I was contacted by an editor at the CMAJ (Canadian Medical Association Journal) who requested that I keep a web diary of the things I was seeing, doing and feeling as a physician in this war zone. I am not a journalist and I am not a member of the Canadian Forces. I am not being paid to write this. However, I am a proud Canadian, grateful for my political freedom and economic advantages, and as a physician, I am especially grateful for my medical education, which was subsidized by Canadian taxpayers.
I am proud of what I think Canada stands for among the world’s nations. We strive for the ideals of democracy, human rights, tolerance, pluralism, the separation of church and state, and perhaps most importantly, hockey. These ideals are the underpinning of modernity — that conceptualization of political, economic and social order that is very much at the heart of this multinational, United Nation’s sanctioned Afghan campaign. There is some pretty good hockey here too! In a couple of weeks a team of ex-NHLers is coming to KAF for a ball hockey friendly with a team of army guys.
But I digress... and before I get much further, a few words about my biases, intentions and limitations. The opinions I express are entirely my own. I do not represent in any official capacity the Health Services Branch of the Canadian Forces, the CMAJ, or its publisher, the Canadian Medical Association. I tend to believe that armed conflict destabilizes rather than strengthens societies; that violence is generally a very ill-advised method of solving conflicts because it usually results in only further violence. I believe that modern warfare is a public health catastrophe and far more dangerous for innocent civilians — especially children — than it is for the combatants. I think that war is perpetuated in part because it is a very profitable endeavour for some morally bankrupt individuals and companies.
However, I also believe, because I have personally seen the evidence, that the Taliban represent the very worst in human thought and action.
I will never forget St. Patrick’s Day 2007 when I and my colleagues at the Mutinational Medical Unit were unable to save the life of an 8-year-old girl who bled to death from shrapnel injuries inflicted by a Taliban car bomb. Any of my esteemed colleagues here could tell you similar stories.
I believe that security is the sine qua non of civil society and that the attainment of security in Afghanistan is an essential goal that Canada can proudly help to accomplish. But I am not an apologist for this war and I have 1 or 2 criticisms to voice that you will read in due course. One of my grandfathers was a Mennonite conscientious objector. The other was briefly a member of the Army Medical Corps stationed in Canada at the end of the Second World War. My wife’s grandfather was a decorated Royal Canadian Air Force squadron Commander who, barely in to his twenties, piloted bombing missions over northern Europe. Therefore, currents of pacifist protest and martial action blend within me and I think of myself (perhaps a little grandiosely) as a loyal civilian critic of the Canadian Forces.
I have been and continue to be unspeakably impressed by the bravery, decency and professionalism of many men and women who wear Canada’s uniform in Afghanistan. It is an honour to work with them and, where I can, I hope to tell you about them and the good work they do.
Every word you will read has been screened by ranking members of the military and the CMAJ to make sure that there is no violation of patient confidentiality or operational security. The CMAJ editor understood it rather nicely I thought: “It’s not censorship in the usual sense, it’s just a question of not saying anything that can help the enemy,” she said. By reading this blog, you will not necessarily know more about reconstruction efforts in this impoverished, war-ravaged central Asian nation of 32 million people. You will not likely learn anything that you can productively apply to your own medical practice. But through my eyes and words you may be by turns enlightened, enraged, or entertained. Thanks for reading.
I am proud of what I think Canada stands for among the world’s nations. We strive for the ideals of democracy, human rights, tolerance, pluralism, the separation of church and state, and perhaps most importantly, hockey. These ideals are the underpinning of modernity — that conceptualization of political, economic and social order that is very much at the heart of this multinational, United Nation’s sanctioned Afghan campaign. There is some pretty good hockey here too! In a couple of weeks a team of ex-NHLers is coming to KAF for a ball hockey friendly with a team of army guys.
But I digress... and before I get much further, a few words about my biases, intentions and limitations. The opinions I express are entirely my own. I do not represent in any official capacity the Health Services Branch of the Canadian Forces, the CMAJ, or its publisher, the Canadian Medical Association. I tend to believe that armed conflict destabilizes rather than strengthens societies; that violence is generally a very ill-advised method of solving conflicts because it usually results in only further violence. I believe that modern warfare is a public health catastrophe and far more dangerous for innocent civilians — especially children — than it is for the combatants. I think that war is perpetuated in part because it is a very profitable endeavour for some morally bankrupt individuals and companies.
However, I also believe, because I have personally seen the evidence, that the Taliban represent the very worst in human thought and action.
I will never forget St. Patrick’s Day 2007 when I and my colleagues at the Mutinational Medical Unit were unable to save the life of an 8-year-old girl who bled to death from shrapnel injuries inflicted by a Taliban car bomb. Any of my esteemed colleagues here could tell you similar stories.
I believe that security is the sine qua non of civil society and that the attainment of security in Afghanistan is an essential goal that Canada can proudly help to accomplish. But I am not an apologist for this war and I have 1 or 2 criticisms to voice that you will read in due course. One of my grandfathers was a Mennonite conscientious objector. The other was briefly a member of the Army Medical Corps stationed in Canada at the end of the Second World War. My wife’s grandfather was a decorated Royal Canadian Air Force squadron Commander who, barely in to his twenties, piloted bombing missions over northern Europe. Therefore, currents of pacifist protest and martial action blend within me and I think of myself (perhaps a little grandiosely) as a loyal civilian critic of the Canadian Forces.
I have been and continue to be unspeakably impressed by the bravery, decency and professionalism of many men and women who wear Canada’s uniform in Afghanistan. It is an honour to work with them and, where I can, I hope to tell you about them and the good work they do.
Every word you will read has been screened by ranking members of the military and the CMAJ to make sure that there is no violation of patient confidentiality or operational security. The CMAJ editor understood it rather nicely I thought: “It’s not censorship in the usual sense, it’s just a question of not saying anything that can help the enemy,” she said. By reading this blog, you will not necessarily know more about reconstruction efforts in this impoverished, war-ravaged central Asian nation of 32 million people. You will not likely learn anything that you can productively apply to your own medical practice. But through my eyes and words you may be by turns enlightened, enraged, or entertained. Thanks for reading.
Friday, March 7, 2008
Introducing the CMAJ Blog
The CMAJ Blog provides immediate impressions from the front lines of medicine. We begin with blogger Dr. Peter Sherk, a critical care physician from Victoria, British Columbia, who is on his second deployment at the Kandahar, Afghanistan, Multinational Medical Unit. Dr. Sherk will be blogging about 3 times per week beginning March 17, 2008 and ending around April 10, 2008. The opinions he expresses are entirely his own, and not necessarily those of the CMAJ or its publisher, the Canadian Medical Association. Please note that Dr. Sherk’s postings have been screened by ranking members of the Canadian Forces to ensure there is no violation of operational security. We welcome your comments on both Dr. Sherk’s postings, and on the CMAJ Blog in general. Enjoy!
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