Pushing Hard and Fast

I've got almost two weeks to straight "clinicals" ahead of me, where I'm functioning as the lead paramedic on a 911 ambulance. The didactic portion of the paramedic class is over and now it's just a matter of finishing up the hours that we need on the ambulances before we test out. These clinical rotations are normally a lot of fun, albeit hectic and grueling as they're stacked back-to-back offering little or no time to rest and recover. Each 24-hour period I will move to a different ambulance service somewhere around the state, quickly learning and adapting to new "truck set-ups" and treatment protocols. I'm expected to be proficient in all of them.

What I've found thus far:

Nursing homes depress me. The smell is always the same. Eyes follow us as we arrive with our equipment to treat and transport one of their own; knowing that someday it will be them on the stretcher- IV lines, oxygen, cardiac monitors, drugs, etc. Elderly, paper-thin skin; mouths so dry that they stick, eyes uncomprehending what is happening to them.

Kids make me nervous. Little people de-compensate so quickly; one minute they're fine and the next they're limp and lifeless. As a parent myself I can feel the unspeakable panic of mothers and fathers as they watch their whole world stop breathing and turn blue in their own quivering arms. They offer you the lifeless little body; tears and screams of desperation follow.

I do not understand drug seekers, but am amazed at the lengths they will go through to get 4 mg. of morphine from me. They know all the right things to say, the coded phrases that almost force me to treat them with narcotics. It's a game to them. When they're found out they go off in a huff, looking for a new source; no embarrassment or remorse, the game goes on.

My Take-Away

This is the one post that, for quite a while, I've known that I would write. For the past three months I've been living with three 21-year old college students and their associated friends. I fell into this situation by sub-letting a room, in their four-bedroom suite, from one of their friends who was traveling for the semester. It's been an interesting and often entertaining experiment.

Firstly, these guys are no different than when I was a college senior back in '86. Nothing has changed in the past 23 years, and most likely going back a lot longer than that. There is still copious amounts of alcohol, good friends, girls/boys, sports, classes, and an over-all attitude of reckless invincibility. The only notable difference, however, is the advent of video games; my suite-mates sit for hours playing all manner of games, including Rock Band, which can be very annoying when you're trying to sleep at 3:00 a.m. I've found this to be the only game that can penetrate the protective cocoon of my Bose noise canceling headphones.

My only epiphany during the entire experience came when realized that these kids are often inebriated, loud, and "out-of-control" only because society allows them to be that way. They're cut free from the confines of home and allowed to rapidly grow and expand with almost no tempering force. The college culture expects/encourages/demands them to act in this manner.

On a side note, what happens when you re-introduce a dampening or controlling force, e.g. you remove the kid from college and enlist him or her in the military? My experience has been that they still grow and mature but not at such an exponential rate. The environment is more supervised, and prone to a lot less recklessness; but that's another post.

During my stay here I've treated several college kids in the ER, one for a very serious alcohol intoxication. The sad part was that her mother came to the ER and had to see her near-naked daughter lying on the table engulfed in an octopus of tubes, wires, pumps, and monitors. I first tried to empathize with the mother, but found it difficult as she viciously blamed everyone for her daughter's condition except the young girl lying before her reeking of vomit and alcohol.

My "take away" has been that if left unchecked these kids will eagerly sprint down an often dangerous path, just as we did at their age; as most of us are lucky to still be walking this earth. There must be some sort of societal, peer, family, organizational, tempering force that allows them to grow and mature, but at a reasonable and less self-destructive rate. When I get home to my five-year old, we're going to work on that one pdq.

Levity In The Final Stretch

Taking a moment to goof around in medic class. Levity and a sense of humor are all-important.


I have a month of paramedic training left; I'm almost done and can see the light at the end of the proverbial tunnel. I'm anxious to get home again and spend some quality time with my family. What's the next step is after that, I'm not exactly sure. I have several options that I'm looking at, one of which is working full-time as a medic in Atlanta. I have some security options, as well, that I'm looking at, but right now the priority is to successfully finish up and to get myself home.

Hanging In There

Little boys, a shovel, and dirt... perfect

OK... I've been blog-lazy for the past few months. I haven't even taken a single picture. My camera lays on my apartment desk, dead batteries and all. I'll fix that.

I'm currently in Bloomington, Indiana attending a paramedic course, and living in an apartment with three 21-year old students. Life is indeed interesting. I spend my days either attending class learning about advanced emergency medicine, or doing clinical rotations on a 911 ambulance or in an emergency room. I've met hundreds of patients with countless illnesses and problems. The fact of the matter is that I quickly forget most of them, however I've come to learn that I'm the most important person in their lives at that particular moment in time, and they will often not forget what I end up doing for them. This is the nature of emergency medicine. I love being a paramedic; mostly because I can have a direct and often monumentous impact on someone's life; someone who is a father, a daughter, a girlfriend. With every patient that I touch, I effect countless others. What a great job!

As I mentioned I'm living amidst college students, which creates its own set of challenges and observations. I look at theses kids, all are 21-years old, and I have to believe that I was once that "innocent"; a word that is a analogous to whatever concept that you want to apply. On a whole they're great guys, and treat me with a bit of awe and wonder. I tell them that I'm not anything special, I've just lived longer than they have.

More to follow in the coming days. I hesitate writing about many of the patients I meet because I'm entrusted with their privacy and confidence, an honor and a privilege that I take very seriously. Nonetheless, I'll try, in the future, to provide some colorful stories and insight as I progress along this path.

College Again

Bike porn: My new Cervelo P2 set up in my room in Bloomington. It'll be trainer rides for a while. It's snowing out here today.

I just arrived in Bloomington, Indiana for a paramedic course that I need to take. Bloomington is a college town, home of the University of Indiana, and I'm staying at a large apartment building that houses hundreds of college students. I ended up getting a sub-let off a kid that was going abroad for the semester and needed to get out from under his lease. Subsequently I'm sharing a suite with three students. I can't tell you what an educational experience THIS is going to be.

Last night one of the 20-something students told me that he was going to travel Europe after he graduated so that he could enjoy the experience "before he got too old". "You're kidding me, right?"

The medic course is going to take up the vast, vast majority of my time, demanding 14-16 hours every day. Added on to that are twice daily triathlon workouts amounting to 14 hours a week. I don't expect to see much of my student room mates, but I'm sure there will be the occasional entertaining episode. More to follow.

The Fixer

An Iraqi father poses with his two sons.

"Fixer" is apparently an Arabic word that means, "I don't wait in lines". Like almost all western companies in Iraq, we employ locals to act as "fixers; to get us through the snags and complications of operating in a foreign land. They use any means at their disposal, some of which can be pretty unsavory, to get us in a position to do our job.

I went to the airport this morning, our lead fixer and I were flying out of Baghdad on the same flight to Amman. At the first sight of a line he didn't even break stride, walking purposefully right the the front of the 30-person line, grabbing my passport as he went. The cacophony of groans and gripes was deafening to my sensitive western ears. The fixer seemed to be energized by it, and pressed on; business class seats, boarding passes, luggage tags all within seconds. I was looking for a corner to hide in as the symphony of disgruntled passengers grew.

This scene transpired not only at the check-in desk but also at Immigration, the boarding ramp, and the bus taking us to the plane. Nothing would deter him. He was like a pitbull. I meekly followed along, afraid to get lost in the throngs of unhappy (pissed off) travelers. I secretly reveled in the "fast track", but was painfully embarrassed at the means to get there.

On a side note, while on the airplane we were handed a form, what at first I thought was an Immigration form for Jordan. Dutifully filling in the blanks I got to the question, "Do you have diarrhea?" It went on from there; "How long have you had it? Medications? Doctor's note?" Not something that you see everyday. They were apparently looking for cholera coming out of Iraq.

Green Zone Chaos

The Iraqis, on the first of January, are assuming security responsibilities for the International Zone, aka the Green Zone. In the past, the U.S. military controlled access to the "city within a city"; home to the Coalition and the seat of Iraq's government. As of tomorrow the U.S. Army will turn over all of the access control points (checkpoints) to the Iraqi army. I shudder.

For the past couple of weeks the Iraqi army has been doing a "left seat-right seat" with the Americans, shadowing them as soldiers dutifully checked ID cards, vehicles and pedestrians entering and exiting the zone. Over time the Iraqis have assumed primacy at the checkpoints while their American counterparts remained in in the background.

As a result the Iraqi army has quadrupled the number of soldiers manning the access points. Now when you drive into the checkpoint you're greeted by a hoard of AK-welding Iraqi soldiers all seriously directing you to do "something", most often in opposition to the direction of their peer standing right next to them; stop, pull-forward, get out of the car, stay in the car! Each becoming more agitated as you fail to comply. It's utter chaos, no one is seemingly in charge and you don't know who to listen to. In the past, failure to follow these commands would get you shot. Needless to say it's both confusing and very, very tense.

I look at the two American soldiers standing in the background, pleading for some sort of organization or sanity. One looks at me and shrugs. Welcome to the future of Iraq.

We Wait

Baghdad ballet dancer waits for class to begin

Update from the previous post:

Our Iraqi staff member was diagnosed with having an acute myocardial infarction, aka a "heart attack". The degree of blockage within his coronary arteries and subsequent damage to his heart could not be ascertained by the Army surgical hospital as it was not set up with a catheterization lab nor equipped to do an angiogram. The cardiologist therefor recommended transferring the patient to an appropriate Iraqi facility where he could get further definitive treatment.

Now is where the fun begins. There are three such hospitals in Baghdad that are equipped to do the needed procedures. The preferred one had no available space, and told our recent heart attack victim to try back in a few days. The second, accepted our guy, ran an ECG, blood pressure, drew blood for labs, and then sent him home. The physician stated that "cardiology really wasn't his thing, and that the real expert was enjoying his weekend and would be into the hospital in a few days". He prescribed some blood pressure medicine and sent our guy away.

The third and final choice was also equipped to do the procedure but our staff member didn't feel safe going there. The hospitals here are wildly secular, and roving armed gangs have been known to go through the rooms looking patients that weren't of the appropriate religious flavor.

Where does that leave us? Twenty-four hours after having an MI our 53-year old staff member with chronic high blood pressure and a significant cardiac history is back at the villa resting in his room. No one has any idea as to the damage to his heart nor the degree of blockage to his coronary arteries. If this were the United States he would be admitted to the ICU and on his way for an angiogram. Maybe a hospital bed will become free tomorrow. We wait.

UA/NSTEMI

A young boy looks on in the soft light of the setting Iraqi sun.

Christmas was punctuated yesterday with one of our senior Iraqi staff complaining of severe chest pain, sweating and vomiting. I took a look at him and knew right away that he was having some sort of cardiac event and needed to get to the U.S. Army-run hospital inside the International (Green) Zone.

I had rehearsed this scenario dozens of times in my head; loading the patient into an armored car, calls being made to the Coalition's press office to coordinate our arrival and reception, treatment inside the moving car through the checkpoints, and speedy arrival into the hospital for definitive care.

Thankfully everything went as I had envisioned it and we got out Iraqi friend in front of a U.S. Army cardiologist in just under twenty minutes. Oxygen, ECG, IV fluids, more aspirin, more nitroglycerin, morphine, x-rays, antithrombotic therapy; all accomplished quickly relieving our patient's pain and eventually diagnosing unstable angina and non-ST-segment elevation myocardial infarction (UA/NSTEMI)

Today, the day after Christmas, we plan to go back to the hospital to visit. I'm thrilled that we have the opportunity to do so. Merry Christmas K.

Bodyguards Beware

A media team shoots a stand-up in the Baghdad streets

I got involved in a discussion the other day about Standard Operating Procedures (SOPs), protocols, and other cookie cutter procedures that would guide people along the correct course of action. My Scottish security partner came out with a saying that I had never heard before, "Rules Are The Idiots' Guide To The Wise". Huh? In other words, SOPs are put in place to help guide someone that doesn't really know what they're doing in the first place. Wow, that's pretty damning, but it's true.

I've seen guys wrap their head around the minutia of SOPs, writing them down, diagramming them out like football plays, making PowerPoint slides, carrying them around in little notebooks. Come on, either you know what your doing or you don't. If you're confident, knowledgeable, experienced, and calm you will probably make the correct decision every time. If you're carrying around the playbook under your arm and constantly diagramming things out on a whiteboard, well, you might be in over your head.

I know this may sound blasphemous to many in the security industry, but to be honest our ranks are filled with guys and gals that would be lost without their playbook, unable to take the appropriate course of action without the SOPs. They're playing out of their depth.

There's nothing wrong with comparing notes with other team members, but it should be nothing more than an azimuth check. If I've got to memorize a bunch of immediate action drills, then I probably don't have any business being involved in any immediate action.

Sunday Observations

In Baghdad's Victory Base Complex there's a coffee shop known as The Green Bean. Not much more than a couple of double-wide trailers glued together with a coffee bar in the middle, it's a popular gathering place for contractors and military personnel. I spent about three hours in "The Bean" today watching the world go by. It sort of reminded me of the "bar scene" in the original Star Wars. Here's what I saw:

• A group of impromptu musicians played folk and bluegrass music in one corner much to everyone's delight. The Brits were struggling with it though.
  

• Several people wearing PT uniforms with drop-leg holsters. It must be hard to run like that.

• A group of cyclists stopped by, out for their Sunday morning ride, adorned in black and yellow Go Army/Livestrong bicycle shirts.

• Five or six people reading bibles. OK, it was Sunday. No one was reading the Koran though.

• An Iraqi army officer fighting through his first ever expresso. He couldn't finish it.

• Waves of khaki colored flight-suited PSD types; blood types scrawled on their boots, patches Velcro-ed here and there.

• Soldiers in dusty ACUs with M4s strapped across their back trying to find some normalcy in a coffee shop.

• Women with a single guy in-tow. Few women are seen alone there. They always have to token male escort, who's happy to go along albeit a bit desperate looking though.

• No Wookies or blasters, but I wouldn't put it past one of the PSD guys to have a Genuine Immitation Luke Skywalker lightsaber tucked away someplace.
  

A Terrible Thing

One of the local street dogs. There are a couple generations in the neighborhood, maybe twenty dogs and puppies in all. They've never been a problem and keep the cat population on it's toes.

This was not good. We returned from a task and were driving through our neighborhood. Up ahead were several local security guys standing in the street observing a handful of guys in white lab coats running around. As we approached I could see the "lab coats" holding clear plastic bags of raw meat in their gloved hands and were feeding it to the very enthusiastic neighborhood dogs. The twenty of so dogs and their recent puppies were devouring the meat as fast as it could be handed out.

This is the Iraqi method of keeping the street dog population down. Each piece of meat was laced with poison, most likely designed to cause massive internal bleeding within the dogs, killing them all within hours. It's an image that will live with me for years, ten-week old puppies sitting in the dirt gnawing gleefully on pieces of raw meat as we drove past.

Aftermath: A few hours later I returned to the street. The dead dogs lay in the dirt along the side of the road. Two fuzzy puppies lay together near a mound of dirt. As tomorrow is the beginning of the weekend they will remain there for several days.

A Good Afternoon

The Baghdad Ballet- Revisited

The littlest dancer

We returned to the Baghdad Ballet School to deliver some gifts that were generously donated by a similar school in Mobile, Alabama. It was a great afternoon and I got a chance to interact with a lot of the kids. I laughed because the only English that they could speak was to sing the "ABC song" and count to ten, which they did relentlessly. I taught the boys how to do an "Obama-style fist-bump", as well as thumb wrestle. American culture is good for a lot of things. I walked away smiling. It was a good afternoon in Baghdad.

Not So Good With Technology

A passing taxi driver. Happy guy.

The Iraqi's have a new device at selected security checkpoints around Baghdad. A serious looking operator holds what looks like a toy remote-controlled car device in his hand, and wearing a pair of earphones, dutifully walks down the side of the car. What he's listening for I have no earthly idea; maybe the ticking of a bomb? Who knows?

This ridiculous display prompted a tirade of comments from my Scottish security partner about how the Arab culture is not the most technologically savvy on the face of the planet. My favorite remark described how you could give Iran, Iraq, etc... the most sophisticated fighter aircraft in the inventory complete with state of the art weaponry and in the end you will still have some guy at the controls wearing a green scarf around his head mumbling "Allah akbar".

I'm not sure why the Arab culture has not embraced technology. Maybe its a function of it's education system; preferring to spend time studying religious subjects instead of physics or chemistry. Quite possibly they don't need to, as they can afford to hire foreign "technicians" to manage things for them. This is certainly the case in much of the Middle Eastern oil industry.

I helped a 30-something year old Iraqi set up his first laptop. I got him a Yahoo account, an email address, login, and password. I did it all for him in minutes as he curiously looked on. When I got to the mandatory "security question" I scrolled through the various options to find one that was appropriate for him. OK, "What was your childhood friend's first name?" He looked at me with dinner plate size eyes and exclaimed, "They know that about me!?"

You Can't Win 'Em All

Ballet shoes sit discarded in a pile at the Baghdad ballet school

I watched an interview with Bill Gates a while back and he stated that he and his wife do not intend to leave their children with a large (or small) fortune. The Gates' would rather see their offspring make their way through life on their own merits and talents, much as they did. Now you can debate the wisdom or justice of this all day-long but I suspect that Mr. Gates, if anyone, fully understands the corrupting influence of great fortune.

I tried to explain this concept to an Iraqi friend today and he looked at me like I had a third eye. There was no way that he was going to wrap his head around the fact that money does not equal automatic happiness, and in most cases it's just the opposite. He believes that money will bring cars, houses, more cars, and even greater houses, all adding up to eternal bliss and happiness for he, his wife, and their children. He found the story of the Gates' intention so bizarre that he ran over an had to tell all of his Iraqi friends.

I took a step back and asked him if he were happy right now. He claimed that he and his wife were very happy... but would be even more happy with a bigger house and another car. I tried to point out people that live modestly with great satisfaction, and others that are swimming in wealth but suffer from depression and a myriad of other ailments. My friend was not biting, and in the end I gave up as he continued to stare at me in blasphemous disbelief. You can't win 'em all.

Uphill Struggle

A Caracas mountain top peaks out through the evening mist

When I first started visiting Latin America in the very early nineties I was struck by the fact that I never saw anyone outside running, or biking. On those very rare occasions when I did see a lone jogger, he inevitably turned out to be a visiting gringo. As a matter of fact, it was considered inappropriate for men to even wear shorts in public, aside from the one-off "football" player. The gyms were sparsely populated by men that looked to be replicating movements from the 1960s' Jack LaLane Show.

Ten or fifteen years later it's all changed; the parks of South America are full of runners, cyclists, bladers and the like. Modern box-gyms are everywhere, as are Spinning studios, and yoga gyms. The Latin population has embraced the pastime of fitness.

The Middle East, on the other hand, is not there yet. In the two years that I've been traveling here I've never once seen anyone running outside, albeit Baghdad is not a 'jogger's city', as my friend jokingly described what he called Insurgent fartliks. The incidence of smoking is through the roof, Middle Eastern men are becoming increasingly fatter, and the cultural diet would make the American Heart Association wince with pain. Unthinkable here is the vision of a women runner, complete with running shorts and singlet. I wonder where we'll be ten or fifteen years from now?

Happy Feast!

Today marks the beginning of the Muslim Festival of Eid that coincides with the annual pilgrimage to Mecca know as the Haj (where the derogatory moniker "Haji" comes from). There is much hugging and kissing among the locals today, akin to the westerners' concept of Christmas. Speaking with one of "our guys" he told me how he woke his family up at 2:30 a.m. so that they could slaughter a sheep (bad day for the sheep population) and distribute the meat to their neighbors. I had to wrap my head around that one, but I guess a fat, bearded guy stuffing toys into hanging stockings is no less strange. Happy feast!

Speed Freaks

Cervelo P2. My new triathlon bike for the '09 season.

I "aged-up" this year, which means in triathlon parlance that I'll be racing in the next higher age bracket, in my case against 45-49 year old men. This is something that athletes oddly enough look forward to, unlike birthdays. In the back of their minds their still 44-years old and racing against all of those old men and women, "I'll certainly do well". Yea, right!

The fact of the matter is that older athletes are doing better and better every year, putting up times that in years past would have swept the event regardless of age. Here are the qualifying times this year for the 45-49 year old age group, times necessary just to get into the Hawaii Ironman Championships; where the best Ironman triathletes in the world are swimming 2.2 miles, biking 112 miles, and running 26.2 miles:

At Ironman Arizona you needed less than 9 hours and 54 seconds.
Ironman Wisconsin: 10:36
Ironman Western Australia: 9:05!
Ironman Australia 10:47 (10.05 for 50-54 year olds!)

Men and women have been competing in these events for decades now, and are currently on the cutting edge of state of the art athletic training techniques. They know exactly what they're doing, and are amazingly consistent year after year in their performances. Some experienced racers are putting up their lifetime fastest times well past the age of fifty!

As Lance Armstrong returns to the Tour de France this year at the tender age of 37, I wouldn't be so quick to relegate him to the back of the peloton.

Two Camps In Iraq

Another shot of the Crossed Swords. Last one, I promise.

I got involved in a discussion the other day with one of the correspondents about her views of the state-of-play here in Iraq. She divides the country's political landscape into two camps; those of the pragmatist and the ideologues.

The pragmatists, Iraqi President Maliki being one, realize that the U.S (Coalition) presence is necessary to provide stability to a very volatile society. The Americans are not the "occupying force" that the other camp would have one believe, but are trying desperately to get Iraq to be able to stand on it's own two feet, albeit for selfish reasons.

The ideologues, on the other hand, are quite willing to watch Iraq burn so long as there are no American or foreign forces "occupying" the land. They represent the radical Islamists that would rather sacrifice their country and their lives, or more over the lives of their followers, than tolerate the presence of a foreign culture on their land.

This is the fight that is waging within Iraq today as it struggles with the status of forces agreement that is necessary to give U.S. forces legitimacy in Iraq in the coming year(s). It has been primarily a political struggle, one which Maliki has demonstrated a great amount of deftness. At times the struggle has turned violent as the ideologues use their greatest weapons to influence the public's opinion. So far it's not looking good for the pragmatists as they continue to use political slight of hand and resorted to putting the decision to a public referendum in the coming months, a public that is heavily sided with the ideologues.

Once More Unto The Breach

The sun rises out of the Jordanian desert.

Back on the road again. I flew from New York (JFK) to Amman the other day on Royal Jordanian Airlines, an airline that I've taken before and like very much. Nonetheless the boarding gate at JFK was a scene of great amusement. As soon as the agent announced the boarding of the flight there was a bum-rush of people stampeding for the air-bridge. The disorganized throng of humanity completely overwhelmed the single, unsuspecting gate agent who was pleading for everyone to form a nice and orderly single line. I laughed to myself and mumbled, "Yea, that's gonna happen".

My experience has been that a lot of cultures don't "do lines" very well, and the Arabs are certainly one of them. There is no sense of chivalry, order, or fairness, just a pushing match to get in front of the old lady in front of you. Politeness is weakness, as a friend of mine once noted of the Arab culture.

On another occasion I let my guard down and permitted an old man being pushed in a wheel chair to go in front of me at the Immigration check point. What I didn't see was his extended family behind him that was accompanying Grandpa. Daughters, nieces, cousins, close friends, and a few strap hangers all cut the line exclaiming, "We're with him". I felt used and my fellow passengers behind me were none too happy with my chivalry either. Lesson learned.