The White Coat Revolt

I’ll be there in a week, stories to follow…

In other news if you’re curious about the progress of the school in west Africa, Gisele managed to finish the second building by putting on a roof, building the floor and buying some desks. There is also a new playground underneath a solid metal pavilion for shade. We now have 105 kids, up from 48. I’m in the beginning stages of organizing a benefit concert in New Orleans to fund the school, shooting for March timeframe. I got permission from the Air Force high command so to speak to take this on as my own project and advertise to the public, which is a huge victory in a world of intangible bureaucracies.

After my last post I started a small fundraising effort on facebook, some of my friends and family had some good questions that I wanted to answer for all to see, and just generally expand the picture on Gisele and her school.

It was asked why the local community does not volunteer time and energy to help out with this? I had a conversation with Gisele about this the other day and to understand the answer to this there are several socio-economic-cultural barriers to be aware of. For starters this is not a small village, this is more of a torn down subdivision (although technically still a village) in the middle of a large city. I make this distinction because if this were your typical poor countryside village materials for a school could be procured from the land. Trees chopped down, boulders chipped to stones, etc.  There have been plenty of instances where communities in more rural settings have worked together to gather such materials.  However, in a city all materials must be purchased, so no collaboration of manpower can be made to procure them.

Also, in a big shanty overpopulated city unlike in a village things for daily living typically need to be purchased, food, water, gas, transportation, what we would basically consider items for daily sustenance. In a more rural setting it may be possible to live off the land. I make this point because it emphasizes how much more important money and income are when trying to survive in the urban vs. rural environment. This may seem obvious, until the parents of the children that are basically getting a free education are asked to chip in and help with the school and the response is an open hand asking for payment first. On the surface this seems cruel and selfish, but if they spend time and energy doing something for nothing then that is time and energy they could have been spending making some trivial salary to buy food to feed the same children, or fulfill whatever other basic needs.

The third point in understanding why the community fails is a cultural one. Its difficult to express completely coherently, but there is a general lack of concern for self-improvement here. The streets are littered with trash.  Piles of garbage often surround empty garbage cans. If you build an outhouse people might be more inclined to pee on the side of it then the inside. To us the fact that kids play on a playground with broken glass, and trash seems atrocious, but to the locals, and for lack of a better category, especially the uneducated, its quite common place.  There is just a general apathy to help each other out. The situation is multiplied if someone offers them something, like a school for example. The local mentality is to simply take what is being given without a sliver of humility and never offer to contribute back to the cause. They are still very thankful, don’t get me wrong. You might be asking yourself, well why don’t they show their thanks? Its just the way the world is here, I’m not sure how else to put it.  Now, its worth mentioning there is a demand for basic human rights and liberties, you don’t have to look any further than the current Arab revolution to see this, but there is a gap between the intention of those rights and what the populous actually does with them. The only loophole I see in this is if the local community leaders like village elders, which Gisele tells me do exist demand that the community help. But, it will take this kind of authoritarian demand.

I was also asked to be more specific about why the local Government cannot help out, or why local NGOs or UNICEF can’t contribute?

Two years ago Gisele approached the ministry of education asking for funds, or land. She filed the appropriate documents, but was told that government funds for helping children/building schools were completely task saturated and was basically told her plight was not desperate enough. And its true, Gisele has done a compassionate thing and built a school for kids that would otherwise not afford formal education and be without any type of schooling, but the government is more concerned about deeper human sufferings such as orphaned kids without a roof on their head, or kids who have no food or clothes and are essentially about to die from poverty. So Gisele is catering to a population of kids that are basically stuck in the middle. They are not orphaned and left to the streets, but they are also not well off enough to afford the eighty dollars a year for formal education. What is interesting about this is that the ministry of education does recognize Gisele’s school as an official accredited school, so it’s more than just a private daycare. This accreditation means she has to meet standards set by the ministry, the same standards it applies to its own government funded schools. The bureaucratic lunacy of course is that the ministry doesn’t give her a dime to help meet these standards. Gisele goes through these motions for approval anyway mainly because of her own integrity and pride that she has an official school. As the saying goes, “TIA”.

Regarding the contribution of Non Government Organizations (NGOs), UNICEF, peace corp, etc. All, I can say is that I’m working on it. I’ve been sending emails in a shotgun approach to whomever I can think of. Yesterday I sent UNICEF a heart felt plead, and I’m awaiting a response. The bottom line is that most NGOs that I know of here deal with providing a service. For example, the peace corp. teaches classes, or builds things in villages. UNICEF has a vaccination campaign, etc. What I need is money, I think if funds come from an NGO it will be more formal and further down the line, in my six-month plan I have doubts about formal NGO dollars, as we need a roof, floors, and new building by the fall. Now maybe I can implore them to help build once the materials are procured. To be honest I don’t know what kind of funds these companies have, I know people have tried to blow the NGO whistle for Gisele in the past and it has failed. But I will try again. On a big plus side I made a connection today with someone high in the state department that might be able to help with funds from that side of the house and is also friends with the peace corp. director for this country, and is arranging a meeting.

The bottom line is that eventually I will need to sell this off to an NGO or more organized entity. The reason is that I had a conversation with Gisele about her long-term goals, where she sees herself in five years, ten years, that kind of thing. She eventually wants to finish this school by building the two remaining buildings, a high quality playground, 24 hour security, hire someone to maintain the yard, electricity, and a couple of shaded pavilions. The total cost is somewhere around twelve thousand dollars for that, in the end she will have a five classroom school. That’s just her one to two-year goal!  In five to ten years she wants to have a primary school with six more classrooms for kids ages six to twelve years old. Then she wants a secondary school with at least seven classrooms for ages twelve to eighteen. So practically my mission in this for the time being is to raise her or procure her the funds she needs for the immediate future of six months to a year. Then by just networking and being generally annoying I hope to convince some NGO to take over and hand them some kind of packaged articulated plan.

Bottom line is Gisele gives unselfishly back to a community that gives her nothing in return. Her heart would break if only one of her kids couldn’t go to school because she no longer had the facility or resources to care for them, and I feel little hesitation in saying that she would give all of her paycheck to prevent this.  She only wants to devote herself completely to expanding and building education for her people, and really all she needs is the opportunity. I just think it would be beyond a shame for someone with such motivation to not be given a chance because they don’t have a voice to speak up with.

Placing a blood pressure cuff on a patient is typically a simple task.  This time was an exception. I felt for the cuff in my bag, pulled it out and went to secure it around the patient’s arm. As I did the floor shifted again and I tumbled forward. I grabbed the guy’s opposite arm to prevent face planting into his stomach. Unfortunately for my patient I grabbed the rubber bone sticking out of his arm that was covered in fake blood. In a second attempt, I was more successful in actually getting the cuff around his arm. As I went to turn the vital signs machine and complete the ritual I paused for a long moment, turned away, and proceeded to vomit in a painfully small plastic bag. Once my stomach finished it’s rude interruption I was finally able to get a blood pressure. After dressing his wounds I sat up for a moment giving my back and neck a much-needed rest from the weight of the armor platted vest and Kevlar helmet. I drew in a deep breath of hot hydraulic fuel tainted air, and took in my surroundings. It was dark in the back of the C-130, and this was important to simulate the tactical environment. Three patients were secured to litters that were strapped to the bare metal floor. A wide variety of medical bags and pelican cases were secured to the floor and walls in any means possible. One of my fellow classmates was off in the far corner tucked into the fetal position clinging to his vomit bag. All the while his pretend patient lay unattended to. As my vision shifted to one of the portholes the outside world took on a dimension of impossibility. What I perceived in my vestibular system to be straight and level flight was harshly contradicted by the ground 500 feet below. The assortment of trees spun by at a dizzying pace with no horizon in sight, which meant we were in a steep bank. In disbelief I moved my head around quickly testing my inner ear and felt the spinning sensation that only comes when one’s ears and eyes are in complete disagreement about the actual location of the body. This act of defiance was followed by yet another wave of nausea, and the lesion was learned.

The point of this flight was actually to induce all the uncomfortable sensations I was experiencing, and still provide some kind of adequate patient care. This experience was part of a larger weeklong course taught at Hurlburt field, Florida. The CASEVAC course as its known stands for casualty evacuation. This course teaches the fundamentals of evacuating patients from combat zones, and typically follows the Special Forces doctrine of “care under fire”. CASEVAC differs from other terms you may be familiar with such as MEDEVAC or Aeromedical Evac (AE) in that CASEVAC typically uses “vehicles of opportunity” to evacuate patients. These vehicles could be anything from fixed wing planes, and helicopters to pickup trucks, and donkeys. MEDEVAC and AE uses designated aircraft and are a more formal way of patient movement.

Another foreign concept that this course introduces is the paradigm shift in medical care that happens in the tactical environment. A few years after 9/11 the military was reacquainted with an old question. How to best treat wounded soldiers in the heat of battle? The observation was made that the most correctable battlefield injuries that resulted in death were massive bleeding and chest injuries resulting in a tension pneumothorax. The solution was to develop a school of thought that could not only address these immediate life threatening medical conditions, but address the tactical situation and evacuation as well, and so Tactical Combat Casualty Care or TCCC was born.  TCCC takes a shift away from more traditional views of trauma resuscitation in a few ways, i.e. bleeding is more important than establishing an airway, and returning fire or “putting lead downrange” is typically more important than anything, there are more examples, but to me those were the most stark. In the end it’s really just a means to establish short-term stabilization until the patient can be evacuated to a safer area where more definitive care can be administered (like the back of an airplane…or fast moving mule).

The CASEVAC course succeeds in not only teaching TCCC, but also simulating a variety of tactical environments to practice in. In addition to the vomit comet flight I discussed above they also have what I think is one of the most technically advanced simulation labs around.  The lab is a small room next to a small conference room in a building that looks like any other official building at Hurlburt. I remember my first experience in the lab.  A group of us were standing in the hallway in full tactical gear, helmets and all waiting to enter the lab when some guy walked down the hall after grabbing his morning cup of coffee, he gave us a slight nod that suggested that being dressed for the end of days and the impending invasion was normal attire in this building. When we were given the go ahead the door opened, the room inside was dark and about 20 degrees warmer than the hallway. The soundtrack was an eclectic mix of gunfire and airplane engines that played over loud speakers. There was a pool of blood flowing across the room that originated at the stump of a mangled leg that belonged to a life size manikin. This manikin, whose price tag I can only imagine was about as real as they come. Controlled by a remote computer it breathed, talked, blinked, and even had real pulsating arterial wounds that spat blood across the room. Accompanied by a medic we quickly began working on the manikin’s wounds. A tourniquet to the leg to control bleeding, a chest seal to it’s gapping gunshot wound on the left chest. After the initial critical wounds were addressed we moved them across the room where a small area was set up to simulate the back of a helicopter. After securing the manikin and litter to the floor we began getting more equipment out to check vitals, establish an airway, etc. At the height of our adrenaline filled resuscitation the lights came on, and the soundtrack shut off. We were given feedback by the instructors observing all this, told to leave the room and then repeated this about three or four times all with varying scenarios.

So you may be wondering why a little one-year wonder, intern only trained flight surgeon cares about the spectacle of CASEVAC?  I think its time to give a brief job description, which to the best of my memory I have not yet done on here. The majority of flight docs in the Air Force typically don’t deploy very often and spend most of their time seeing relatively healthy clinic patients, writing medical waivers to allow aircrew members to keep flying despite a history of well managed hypertension, attending rather mundane meetings, and keeping up with flying hours. I’m not bashing the average flight doc, its all well and good, and can be a rather enjoyable life style. But, given the opportunity I would rather do more. The “more” presented itself in an opportunity to be part of something called a Special Operation Forces Medical Element, or SOFME as its known.  A SOFME basically provides medical support to an operational squadron or any special ops units at really any location. This can range from large bases to small bare bones forward operating bases. The real guts and glory part of the job is to provide emergency medical support to a deployed SOF unit. Generally speaking this means far forward CASEVAC, and short-term casualty holding and staging for Aero medical Evacuation.

The team at its opportune capacity consists of a flight surgeon and two independent duty medical technicians (IDMT). The medical gear to fulfill this mission objective obviously has to be miniaturized and tightly compartmentalized, and then it has to be adapted to work in whatever type of vehicle is used. So to put it frankly, knowing how my shit works is a big part of the job.  The CASEVAC course is only the first step in getting acquainted with this art. Back at my base we run exercises as frequently as we can to continue practicing. For something like this practice not only makes perfect, it makes sure people don’t die, because up in the air above some battlefield I don’t have a senior resident I can turn to and ask questions about what the hell I’m supposed to do next.

As the cold front settles in on Baltimore, the snow begins to fall, and the roads begin to freeze.  On this chilly Friday night, bartenders are closing tabs, drunks are falling over, and triggers are being squeezed. As darkness looms, the revolving front doors of Shock Trauma make not a whirling sound, but the “cha-ching” sound of an overworked cash register.

The first business of the evening is a prisoner who attempted to commit suicide in his cell. Of all the creative ways to kill yourself, tying one end of a plastic bag to the top of a bathroom mirror, the other end around your neck, and sitting on the sink while leaning forward has to be one of the worst idea I’ve heard. This guy was completely fine when he got to me; he was coherent and talking up a storm. He eventually transferred to a bed upstairs. I got a report later in the evening that he attempted to kill himself again. It fascinates me how he could have done this while shackled to the bed with two guards watching over him. Maybe he just held his breath for a really long time.

The next unhappy customer was a seventy-nine-year-old active gentleman who rolled a little too far out of bed and landed on his neck. When I first heard the report, I yawned a little; after all, how bad could a fall from fewer than 3 feet be? On my initial exam, he had no feeling below his neck, couldn’t move any extremities, and was having a hard time breathing. I didn’t need to go to med school to know that something really bad was going on here. He was intubated to protect his failing airway. A CT scan of his neck revealed that had essentially dislocated his C4 vertebrae over his C5, completely severing his spinal cord in the process. He would remain a quadriplegic for the remainder of his short life until his family withdrew care the following morning.

A short break for a midnight snack was interrupted by a combative, intoxicated mid 30’s female who smashed her car into a telephone pole. As she was sitting up in her stretcher cussing out the nurses, it was clear her airway and breathing were not going to be an issue. In my head I was debating about giving her some ativan or haldol to calm her down. As soon as the thought crossed my brain, I turned and saw anesthesia pushing propofol (a powerful sedative), and getting the laryngoscope ready to intubate her. This happened a couple more times throughout the night, and I learned the lesson that if you don’t cooperate in the Shock Trauma TRU, you go to sleep and buy yourself a breathing tube. All of her CT scans were negative. In the morning she was still intubated at 8am, and at 10am she was discharged. The standing protocol to extubate a drunk seems to be turning off the sedation and decuffing the breathing tube. When they wake up, they naturally pull it out and walk out the door.

Somewhere around 3am a frantic paramedic came through the intercom. The description that followed was a twenty-something-year-old girl found down with a heart rate of 30-40, and a blood pressure that was so low, it was barely reading on the machine. As my vital signs did the opposite of her’s, I quickly reviewed all my pocket resources for how to run a cardiac code. The girl was wheeled in and it was very clear she was severely intoxicated.  When we measured her vital signs they were low, but not low enough to wheel out the crash cart. She was intubated and given a bunch of IV fluids. Her blood alcohol level was .350 when she first arrived, about 4 times the legal limit. The surreal part was when she woke up in the morning.  This girl who looked like any other early-to-mid-twenties college coed was walking down the street one moment and pulling out a breathing tube in what looked like an emergency room the next. When we rounded on her, she was sitting up in bed with tears of embarrassment in her eyes, asking where she was.

Occasionally the University of Maryland brings in a film crew to document an average Friday night at Shock Trauma, and this was one of those nights. They use the footage for, I was told, a variety of things from documentaries to advertisements.  As I was doing an initial assessment on a nineteen-year-old involved in a rollover car wreck, there was a giant camera pointed at me with a boom mike hovering above the patient. It made the whole experience feel like I was on a set of some daytime soap opera.  My nurse, however, was not a bustling blonde in a miniskirt luring me back to the call room.

As the night turned to day, the intercom that communicated with the ambulances settled to a pulseless dial tone. The real pain began at 7:30 am, after admitting 27 patients overnight, we had over 50 to round on. We finished somewhere around 2pm. I promptly went back to my shared hotel room and slept for a solid 15 hours straight.