Banks, Patriots, and Nada Trickling Down

In this post Ronald Reagan society, a chasm came to exist between the have and have nots, and the middle class fell in. Rarely heard from again, they were sometimes represented in the third person by leaders who spoke of them with feigned familiarity, as you would a distant uncle that you cared about but would not take into your home necessarily.

The constructs that allowed this chasm to be effected in the first place were the brilliance of the marriage of politics and business. If you were invited to the wedding in the 1980's, it's likely you're remembering the decade with tremendous fondness. Alternately, if you were cleaning the grounds after the reception ended like the rest of us, it was a rough ten to fifteen years. Long decade indeed of watching the chasm grow. And then the sky widen.

There was wedded bliss in this most unholy marriage of politics and business. Deregulations occured in industry; tax code changed in favor of the wealthy and for big business; environmental regulations were altered to favor exploration and pollution; restrictions were lifted for tax shelters; capital gains taxes were newly minimized; ...all of this while the interest rates on a home was 13%, there was no raise in the minimum wage, Pell Grants were under attack, and ketchup was declared a vegetable on school lunches to meet national standards.

In brief summary, if you had money already, it became far easier to make more. If you did not, it became more difficult to get a higher education, buy a home, or make a living....or get a balanced school lunch if you were, say, a third grader. (Buying a home with essentially just your signature would come years later, when it was as easy as getting coffee at a drive through. And we see how that worked out. A lot like coffee with an ill fitting lid and a manual 5 speed. )

 Then there came a time when there wasn't wedded bliss anymore, two decades later. It had been a good ride for many, no doubt. But you may have heard it was all too big to fail, and those who had been at the wedding in the first place gasped and took charge again. Or perhaps it was their offspring, who had likely never known that ketchup was a vegetable.

Nevertheless, they found ways with other people's money to make the failure look more like just another typical day of losing other people's money, instead of a world crisis of banking collapse. When they make mistakes, they may be big ones, but they do have resources to tap, and they are sized to scale.

But this is not a post to grossly oversimplify the banking crisis. It is a means to suggest that the absent middle class has had an unintended consequence of creating a disaffected citizen, and this disaffected citizen has co-opted the word patriot.

This is troublesome. Patriot means someone who believes in one's country, loves the country, stands up for it, all of it, right, wrong, and all of its people. There is meaningful, thoughtful dissent as needed. Patriots do that too.

However, it seems the new example of patriot is closer to someone who is xenophobic, territorial, and ready for a fight. Even if they don't have the facts straight.

While you have to love their pure emotion, still, facts are a key part of arguments, especially public ones, and when you're representing yourself as a patriot, it makes the whole country look foolish if you argue with one part facts and two parts emotion. And seemingly half a brain.

They have minimized the meaning of a powerful concept, put on a tri corner hat, and used the word to further interests that are unique to a minority.

It makes perfect sense in a land of free speech to call yourself anything you want. That should be applauded. But patriot, in this context, is a stretch. The agenda of some of these would be patriots includes freedom of speech, for instance, for some. Them, to be exact.

Being patriotic doesn't mean saving your country just for your own kind. It means saving it for all kinds. The new use of the word, again, is exclusive to saving themselves from another people here in the US. This isn't patriotic. It's decidedly not in keeping with any American doctrine.

We can be certain that no one was patriotic, one way or the other, when business and politics headed for their lengthy honeymoon 25 or so years ago. (Did they go to the Caymens, a well known getaway for tax shelter purposes?)  This had nothing to do with the good of the country, and everything to do with the well being of personal wealth. Nothing patriotic there.

And Mr. Reagan, wherever you are, it did not trickle down.





 

No ICD-9 Code for Shared Understanding

- A Head Start physical exam that becomes  advice from a 5 year old about how to get your first bike: "you crush cans until your grandma says you have enough money".

- An elderly woman's "dizzy sometimes and tired most of the time" work up, the kind that can be so unrewarding in terms of hard information from the lab. But the patient adds at the end of the visit that her son is the Medicine Man, the Shaman, and this is just a second opinion.

- Colleagues after a holiday weekend, Health Aides, giggling about sore muscles and chatting about the best recipes for frying the pinon nuts they have gathered from a field, on their knees, all day yesterday. Their families may have different recipes, but the basic facts are shared with me just the same, once they switch to English and finish laughing at their sore thighs.

- Preparing to intubate a very elderly, dying woman who can't breath well at all, with two other generations of family about to leave for the hallway. Then, before the procedure tray is ready, having the eldest daughter stop the procedings to talk about doing nothing further for their loved one.

Being a PA is a ticket to a world that is sometimes intimate with strangers, vulnerable with colleagues, and rarely free of opportunity for the details that make us human and infinitely interesting.

I share these notes from the front line of medicine because so often I find what we do is dehumanized once it finds its way to print. Maybe even before it becomes electronic ink; maybe while it is still forming a thought in the minds of those who would think of medicine as consumed or purveyed. In the present state of bias and disconnect, the patients are sums, the clinicians are producers of income, and the product of our work is reduced to the grand total below a bottom line.

I challenge anyone to summarize my work, by the metric of a day or a career, by a number you find below a bottom line.

Those of us in between the consumers and the owners ( the ones who deliver) are not, speaking for myself, comfortable with the present model of life as a statistic. Especially when that statistic is so boldly linked to a commercial commodity that is to be bought and sold. Or, in the current case, held ransom by insurance companies.

Health care should not be for sale as if you were buying a car or a house, say, for a major disease. Or buying new shoes in the case of, perhaps, the flu. There should be no negotiating necessary, no fine print, no lawsuits to get it right on redux, or bankruptcy when the right balance was not realized.

It's the mark of a civilized society to figure out how to care for the health of its citizens. All of them. Each of us. Just as we have built a functional, safe interstate highway system since World War II, and managed complete and thorough environmental protections that did not exist before the 1970s, and an entire space exploration program since the 1950s, just to name a few major federal projects, our country has proven that with focus, big successful and expensive things can happen.

No doubt there was resistence to something as outlandish as Interstate Highway I-40 cutting ramshod across the landscape when it was first proposed. Why can't people just use the perfectly good two lane system already in place? It has worked for years! Route 66 - love it! Don't change a thing!

But like Rt 66, whose time had passed by 1950, those who have enjoyed their time at the health dollar trough for far too long need to step away. Business models would have to change dramatically, and this, of course, is why change has not come already. Money doesn't shift to places of need from the stronghold of greed on its own, irrespective of the legitimacy of need. This could be an axiom of poverty.

Over time, business models favoring the greed of health and insurance care have become legislative realities. It's no surprise when businessmen become our lawmakers how this could happen. It's predictable. Should we think they are going into politics for statesmanship? Really?

Rules don't need to bend at all when laws are made to support overcharging patients and bear no oversight on insurance company fraud. When the things insurance companies do sometimes walk, talk and look illegal, well, it's because the definition of robbery was purchased by those who lobby for these companies and with enough money, definitions can be blurred beyond recognition. Insurance companies function nefariously with impugnity because the laws simply allow it their way.

Changing this will be like turning a very large train. One, unfortunately, that does not care if you and I and all of our patients are on the tracks. Historically, anyway, we've been on the tracks already and nothing has slowed the train. There is a body count. It's just difficult to apply exact science to the quantification of who died from lack of preventive or diagnostic care, or who died from lack of chronic need medications, and who died from failure of ability to pay for a life saving surgery. But they were all on the tracks, these folks, when the insurance train sounded in the distance. And they were not covered. Or they had not met their deductible. Or they were out of network for the specialty. Or the requisite waiting period was not up. And the train just kept coming, because trains are unweilding machines.

I told the little Head Start princess that she will likely be the smartest girl in her class. Who else had earned enough money for their own bike at her age? I sensed an eagerness in her twinkling eyes and a grin, albeit absent one front incisor, that would take her far from her grandma's careful accounting.

Grandma just looked on, pleased with the course of this exam and conversation with her young charge. Our eyes met for a fraction of a moment. There is a graceful understated humility in the people here that can bring me to a caring silence. I'm in a place where less sometimes is more. Less, in this case of shared understanding, can be the greater part of the whole.

And, thankfully, I have no idea how to bill for this, a moment of invaluable human connection.







 

Honest Patient Honest Dollar

In this business of medicine we are typically hurried along in our patient care duties by unseen forces, such as adminstrators, who enforce expectations of speed. The underlying impetus for this is institutional income, of course. It's not an intransparent truth. When, at your annual check up, your doc or PA seems to be speaking in half sentences and glancing at the door, it's likely because this professional is under pressure to see more patients per hour.

However, in a location where I work currently, there is no money to be made per patient. It's just the way the money flows from one hand to the other within the government. So the need for speed is due to patient flow, not administrative hand wringing over a keyboard. We still go fast. But it's because the patients show up fast.

Yesterday, for instance, I was asked to go quickly by a patient with multiple problems because, she explained, her sheep were being stalked by a coyote lately. She could only be here a little while.

Intrigued by this sincere concern, I asked why this was a problem now. I guess that's the ER person in me; the question of immediacy is ingrained. She informed me that her best sheep dog has gotten too old to take good care of the herd, and the three new puppies aren't trained well enough to the task. Plus, her mother is too old to shoot the shotgun straight anymore. So, would I please hurry. She can't afford to lose any more lambs.

Accordingly, I hustled with a quick step that no email from a hospital CFO had ever put in my Nikes before. I imagined the coyote checking the dirt trail for her old pick up, then peering at the lambs, then back at the trail.....

And before long I had her exam done, her meds refilled, and our requisite chat about the exam, plan, and medications completed. I watched her perfect black braid trail down her back as she left the room, and I wished her lambs well in my mind.

A More Lighthearted Look...

If you read that August 18 post and think we only export angst here, this video from the Funny or Die people shows that dark humor is also offered from where power and prejudice reside in tandem in the governor's office:

http://www.funnyordie.com/embed/ccf82db57e

Meanwhile, here in the Navajo Nation, the days are shortening and the temperature is dropping. It's still August. I have my beloved winter beanie on - the one with the colorful border trim. It's like a basic bean and rice dish; no matter where I go in the world, it seems to fit in ok. Or at least I think it does.

Just to be reminded that I'm still in Arizona (if the occasional internet news isn't enough; there's no TV), a 3 yr old boy was bitten by a rattlesnake this week. He was whisked in by his frantic mother when she realized what had happened. I saw a swollen, slightly bloody foot, and thought it might by a bite from a small dog. I was wrong.

The entire lower extremity began to swell and darken with an alarming speed, and the child was inconsolable. As many reading this will know, the key is to keep the patient still and calm. So he was back boarded and sent traveling in the waiting ambulance the 50 miles to Chinle, where there is anti venom. An RN went with the paramedics for further support. By that time his foot and leg were so swollen it was difficult to see his toes; he had apparently received a large dose of venom.

From the Chinle Hospital, he was medevaced to Phoenix Children's ICU, where his definitive care proceeded. Rattlesnake bites break down the components of the blood's clotting factors, and his were indeed breaking down. It's as if you ingested rat poison, or all your granfather's coumadin at one sitting. The labs supported that ominous knowledge about this snake. Ongoing messages we are learning is that his condition is stabilizing.

In the Navajo tradition, rattlesnakes are not to be killed. Instead, they are asked to leave. I do hope by the time this family returns home there has been a ceremony to encourage their herpetologic visitors to move on.

The deluge of overnight rain has ended with the gray sun's meek arrival. My morning run will be muddy. On mornings like this, every being will leave their paw prints for me to see.





 

Not Just Any America

I returned to the United States from working in a small space in Kurdistan, and from being off leash in Istanbul. Indeed I did. I kissed my dog, hugged my friends. I went to Haiti to do what Peacework Medical does so well there.

And upon my return I repeated the activities listed above with my dog and friends.

Then I decided to earn a paycheck again, and ventured to do this in the United States. But this would not be in just any American enclave. This place where I would warm my stethoscope would be the very sinus node of our country. For those who avoided cardiac anatomy, I'm alluding to where a heartbeat begins.

Specifically, I'm working in the Navajo Nation. Without argument, where America thrived in spirit and culture before it had this name. Before we had names, and lumbered in on horses and carts with too many things to name in one sitting.

There is a distinct irony to be working among our native population here in Arizona.  Frequently needing an interpretor to communicate with my patients, who speak the indigenous Navajo language, and being witness to an ancient culture, reminds me that I'm a newcomer to this land. Times like these I feel like a foreignor in the United States. I remind myself I'm in Arizona at least once daily.  It's an intriguing juxtaposition of time, place, and circumstance.

The irony exists in that our governor is currently wielding all the power of her office to deny certain other newcomers to our land any benefits of human decency, dignity, and opportunity. She has essentially blocked the federal "Dream Act" in its practical application here. It exists by law; it's just been skeletalized in how you could actually use it. For instance, now you can't get a driver's license if you're a part of this effort...she was able to unilaterally block this and other parts that make it impossible to follow through on the Act itself.  Vindictive and petty.

This is the treatment for people who never walked into the U.S. on their own; their parents brought them in as children. It wasn't their choice to arrive, but it has been their choice to learn English, engage in the culture, and become a part of what is now known as the Dream Act. Simply put, to continue their education and/or serve in the military. Reasonable goals for any young person who would contribute to the land we all share and call our  home.

So while the governor appears to have had relatives who may have escaped a potato famine, or been in a nearby country who may have shared a potato as they were departing for the New World, she herself forgets that we were not here first. And we were not particularly welcomed with open arms either.

This fluke of circumstance that has hoisted her to the top of the heap is fleeting, and her bias toward those in positions of less power in society is stunning. We should behave more like guests, and perhaps this should begin with respect for all constituents: the powerful, the powerless, for those who have been here since her family was planting seeds on European soil, and for those just learning to dream the American Dream.

But you might not seize this big picture of the value of inclusiveness and attention to history when your education  extends to a community college certificate, as hers does. And the legislature she oversees overwhelmingly matches her at this level of higher learning. It's true: fewer than half of this state's lawmakers have bachalaureate degrees, something that could help with pondering the world beyond the lines drawn around your district. I can't make this stuff up.

If I did, it would be duplicitous, and I would need the authority of, say, congress to get away with that. And less of a conscience, perhaps like the men and women in the downtown Phoenix halls of Congress deciding to abrupt the futures of motivated young people. The very ones who want to legally go to college and explore beyond the Arizona counties they were born in.

They could make Arizona a better place for all of us someday, with ideas and innovative drive consistantly shown by immigrants in this land. Or they could be relegated to become short sighted, poorly educated citizens with dead end jobs. Education and opportunity make the difference. Divisiveness breeds hate. How can a governor willfully perpetuate a heirarchy among our citizens, and create a place where there is discrimination for its own?

#21. Springtime in PHX: The Edge of the Abyss

Springtime. The very thought of it inspires promise, hope, rebirth...all the things that winter may have left sleeping if not for the equinox. The desire to be outdoors is perfectly timed with longer days and new musicians at Happy Hour on the patio. But this is Phoenix, and at some point in the past it was named the Valley of the Sun for good reason.

This is a reminder that the other sandal will proverbially drop. When it does, and this has little to do with the solstice date on the calendar, the annual apocalypse commonly called summer will take place. It will not be kind, and this unkindness will be shown in ways that nature manifests her indifference to water based creatures - all of us who are one liter low just for having slept through the night.

I have loved the coming of spring. There have been times I've longed for it, and I have spent many years free of concern over a second sandal dropping at all. There were springs when I've  lived in places that were too chilly for March sandals anyway.

For instance, one winter I endured the fits and gasps of winter living in an abandoned farmhouse near the Appalachian Trail in Virginia. By definition, this is at some elevation, and also by definition, the abandoned part meant I was heating with downed wood that I chopped myself. These elements will make you wait impatiently for  the coming of spring.

It was a long cold season, with my closest human neighbor too far to hear a car horn, but raccoon, fox, and deer were ubiquitous and living right next door in the woods. The latter were in cahoots for the prize that was my dog's bowl of dry food. The bowl was indoors, and the critters were generally outdoors, but this dynamic of need met with denial created a challenge that threaded through our long nights and short days together . Obviously before my arrival there had not been fast food on their side of the county.

 I was never sure how they conspired to open the front door, but they often did. It didn't have a functional lock, but there was a doorknob to manage. Nevertheless, there were times I met one species or the other on my wood floor kitchen, much to our shared shock. My task was to quickly move out of the way of the now wide open front door to allow a hasty exit. There were always crumbs of dry dog food left in the wake of these rendez vous.

When late March finally arrived halfway up this mountain, an unexpected crop of wild irises lifted through the thick blanket of brown oak leaves, dried timothy grass, crushed acorns, and thin morning frost. They were purple with deep yellow and thin white edges. There were dozens of them in the meadow that served as my front yard. Each was shorter and stronger, but no less beautiful,  than the cultivated ones you see in florist shops. I supposed they were a parting gift from a winter that had not quite made me leave or left me permanently frozen. And they were an early Easter bonnet in a natural world that can be surprisingly delicate and generous at times.

But springtime here in Phoenix, albeit quick and not without the consequence of a trailing apocalyptic summer, has been everything a tourist brochure could fit onto its pages. It's a transcendent time to be outdoors, from daylight until whenever you want to call it a day. My dog Lucy knows the meaning of dog tired. The wheels on my bicycle have made a respectable number of revolutions. I've seen enough NCAA basketball this month to possibly be qualified to substitute for Dick Vitale if he needs a break next week. And importantly, there are empty food containers gathering at friends' houses as deliveries are eaten from my kitchen.

March has been a good time to be between jobs. At this point, however, the balance of that period is tipping toward packing the stethoscope again. It's almost time to get back to work. Remaining flexible, I'm not sure when exactly or where at all, but I do know that it will occur in a foreign land with a new contract soon. After all, springtime is the season of renewal and hope. Add optimism, and it's easy to forget about the other sandal for a while. We call this place home for what it is, a valley tipped toward the sun. For now, the angle is perfect.

#20. Off Leash in Istanbul

The snow and slush in the streets was just a little higher than the edge of my running shoes, but the Byzantine tunnels were warmer, intriguing with their arched mosaic ceilings, and with darkness approaching, the light deep within completely irresistable.

We sometimes use the word Byzantine  synonymously with a description of winding and complicated. These tunnels are called Byzantine because they truly are winding, complicated, and from the era when Constantine ruled the Roman Empire from this city he named Constantinople. They are, in fact, Byzantine tunnels.

Not incidentally, a young Ottoman Turk named Mehmed came in and overthrew Constantine from power, changed the name of the city to Istanbul, and effectively ended the era long  known as the Roman Empire. Thus,I had just spent nightfall wandering through ground zero where Christianity and Islam originally threw hats in the ring.  And of course I had exited from a different point from my entry, and was lost in a city whose language, street signs, culture, and ambient temperature was not my own.

Being lost in a major foreign city is not newsworthy; in fact, my not being lost in a major city would be worthy of an essay all its own, and possibly a media call. So I do have contingency mechanisms for this predictability. First, it's best to stop and eat street food when you're lost. So I had the lamb that was steaming upright on the skewer and being shaved with great skill by an animated vendor.

This allows time to watch how the taxis and buses work, in case I was hopelessly lost on foot and would require mechanical transport.  Taxis are like living independent species of animals; they behave differently wherever you go. So they demand observation from behind, in this case, a plate of hot lamb and Turkish coffee. I considered some tea as well to dip my slowly freezing toes in, but thought better of it.

Being lost and subsequently aquiescing to taxi use has sometimes proven to be hideously embarrasing for me and perplexing for the driver, since the hotel can turn out to be just around the block. I'm certain the driver goes home and says, "Honey, you'll never guess what this (fill in the epithet for aging American skinny white lady) did today.."

But what I saw were tram tracks that might lead me back to my correct street. I do find myself in cities that don't trouble themselves with street signs. Or sometimes when they do, the alphabet is one of the many I didn't learn: Arabic, Thai, Khmer, Viet Namese etc... So simply remembering the address of my hotel is not enough when asking questions of strangers, assuming there are English speaking strangers.

In response to this reality, I sometimes don't even bother with the hotel address, which is often a worthless bit of information, even for taxi drivers, who often are not exactly professional drivers. Instead, I retain in memory the nearest major landmark that, supposedly, most locals would know. In this case it was Istanbul University.

I was following what I thought were my tram tracks, in what I thought was my direction back, and I spotted a young man who looked like a university student. So I asked him where the university is. He not only spoke English fairly well, but he knew where it was located. He was delighted - I think because his classroom English had flourished effectively in real time. I was delighted too, because I was closing in on warm dry socks.

I was on the right street, just going the wrong direction. As a practical fact, this has happened more often than I have patience or memory to list. As a philosophical reality, it pays to keep your about face move sharp.

Of course I made it home to Phoenix. Airports with signage that includes English as an afterthought is a specialty I hold dear right along with, say, Word catheter placement. Total flight time: 21 hours that included 3 flights. Total travel time: 72 hours that included 26 hours in lovely, frozen Istanbul.

My dog Lucy and I have remained inseparable. I've been visiting with friends and eating anything but Chicken and Rice, the Consulate mainstay where I spent the last 35 of the 105 days in Kurdistan. Lucy doesn't ask any questions; everything with her is unconditionally accepted. For instance, when I originally adopted her from the humane society, she did not ask why I hadn't arrived the previous week; I was here now. And that set the tone with her. Perfect.

 Friends, however, have asked what is good about the work. There have been other questions too, but that's a good question with an answer:

Singularly, the thing I enjoy about practicing medicine in relatively austere conditions with limited resources and the threat of potential violence is that there is no one prodding me to go faster for profit. I will go fast if it's indicated on behalf of the patient - not because of an administrator's demand.

There is no bean counting of the patients per unit of time, or revenue units of  care incurred, or coding of the nuance of how a product was dispensed, or any of the things attached to our work to make our every word or action billable. The patient care is simply accomplished as needed, a note is written, and the room is cleaned. My job is to get the patient healthy and back to work, not to create a bill for him to pay.

I had to go to the other side of the world and occasionally wear body armor as part of the daily job to avoid artificially created stress for speed and  bi-weekly post-it notes from the billing department. I must always have in my office a Kevlar battle grade helmet, but its purpose will never include deflecting e mails from how a chart could have been made more profitable.

 This journey has generated no regrets.  Well, I miss my dog; not a regret as much as a foreseen reality. But for these weeks ahead, she is sticking by me. Unconditionally.

#19. 100 Day Retrospect & Action Over Words

This employment contract has reached the point of one hundred days. It's time for its first leave period. This gives me a chance for a knee jerk primary retrospective.

Without anything else coming close, professionally anyway, the salient event has been the US military departing this country. What followed was an instantaneous crumbling of the coalition government and resulting sectarian violence.  Before you could say "Is there one I in Shi 'ite or two?" and " who forgot to turn the fan off because I think there are a few letters of the alphabet about to hit it"  they already had.

(editor's note: the writer would like to distance herself from any religious overtones or even undertones in that last remark. If anyone read the post "Redux: The Day the Music Died" she has learned her lesson and the current IPod is successfully in a witness protection program. )

US civilian workers checked and rechecked our emergency plans. While no one actually counted the number, I would guess the years of collective work experience in emergency medical response meetings around those tables was well over triple digits, a veritable Methusala of a working group. Just our elbows alone leaning in were weighty with experience.

However, I would also guess no one had made these plans with so few actual resources. Of course there were some basic ground and air equipment, but you just can't call the Cav anymore, like the way John Wayne did with his gold kerchief in a war far away. You can't just call air support anymore, when you need more helicopters than what we have parked and well equipped.  And it doesn't really help to tell the stories about when you were able to get all the help and resources you needed. Nice, but no help. In balance, what we don't have, at the moment anyway, is an enemy to fight. Now that should cut back on some of the bulk.

Our job now was to act smarter and leaner with less than ever before, and the plans, both large and small, had to reflect this concept. It was a little late to order "Who Moved My Cheese?" in cheerful boxes from Amazon, because the military had also left with the only mail service. This paradigm shift was like geologic plates moving below the feet of contractors left behind, with mail service being the least of the vacuum created.

I'm not the physicist to explain why nature abhors a vacuum, the phrase we were told to repeat in earth science, but the suckage here was making people feel the inadequacy of what I will collectively call "back up". Look behind you, and you either saw a T wall or the desert, depending on your vista, but you did not see your tax dollars at work in the form of military might flexing to hoist your broken bone to the nearest orthopedic surgeon. That was going to be left to our planning imaginations, and we were on it. Elbows on the table, focused, lists being made and maps being drawn. On it.

 Imagine 911 going down permanently where you live. Everywhere. And  your, say, local two bay fire station is told to come up with a plan for your entire county. That's not a perfect example, but it's probably the closest analogy between a US domestic situation and here. Your fire station is small. I'm just here to remind you. (Don't mess with my Ipod if that made you antsy. Just saying. )

The neighborhood we woke up to on December 19, 2011 was no longer a planned community with a jolly mayor and weekend softball. Instead, there was a careful recheck on the big lock on the metaphorical back gate, without a clear sense if it was to keep potential marauders out or hold us inside until the plans for movement improved. Literally, though, there were periods of no movement at all. I think "batten down the hatches" is a Navy term, but for some reason it came to mind, like the way I felt when a hurricane would take aim at the Outer Banks from the wide expanse of the Atlantic. Not many Navy men here though, mostly former Marines and Special Ops, so I may have been the only one thinking in obsolete mariner terms.

Those with recent military histories seemed to be watching the taillights fade through the dust, if tanks had taillights, and if they weren't already well into Kuwait anyway. It was that thousand yard stare, like when you need water in the desert. For a few there was a direct inverse relationship between their former military rank, number of years served, and the ability to make new plans at the tables mentioned above. There is really no other way to put it; it's as if there was a period of utter disbelief in the pullout "Can this be happening?" that would make it return to their baseline normalcy. It was never expressed that clearly, of course. It was just that through examples of then and now, the contrast became not only clear, but absolute and permanent. We would now become surfers of the contrast. And try as I might, I could not picture some of these guys in board shorts waiting patiently for the perfect wave.

 But in reponse to this observation of the men who were carefully brought into the present along with their intact intellectual skills, I would like to propose a new ICD9 nomenclature:  "folie de group think", which would follow the ever popular folie de deux.

I guess it was a different folie de group thinkers who had predicated the whole WMD phenomenon in the first place. It must be something about this land of Mesopotamia that elicits this particular folie. The antiquity? The sandstorms? Our country's sometimes inter generational executive branch of government's preoccupation with creating a solution for which there is no problem?

 But we of the heavy elbows eventually all got on the same page; these are smart guys, but imagine your entire trillion dollar tool box being wheeled away and you're left with a hammer, a Phillips head, and a Swiss Army knife with the tweezers missing. What is this --McGyver Goes to Haiti? Speaking for medical assets, plans were made, trained and tested. Then we had  several actual medevacs including a serious vehicular trauma to further challenge the plans in real time. It all went relatively smoothly, not that there were no thoughts of the Cav or air support to swoop in and provide heroics, but we managed to salvage the day anyway. Patients had good outcomes. Meanwhile, thankfully, there has been no mass casualty, although this threat is never off the planning table.

And this is how you build a new body of confidence. It fills the vacuum.

Confidence is built on superlative action, not in tabletop planning alone, comforting words or historical tales (although I love a good story.) All of us here have plenty of the latter, and most of us have met adequate measures of the former as well. Day by day, it's a standard we have to attempt. If you're comfortable with the way you are, then get used to it, because without effort there is unlikely to be any improvement. Nature doesn't seem to push things uphill.

It's the deed, not the word, that's as real as the blood pounding in your ears when you doing what you've trained to do and get it right. Only actions build confidence, both in yourself and in others. Can this country right itself? I have no idea. But those of us here are working alongside local nationals, and their numbers are increasing to 50% of this workforce . They need training and confidence. It's a model for them as individuals and for their country. There are no short cuts. And the mission is a long, long way from being accomplished.

#18. Relentless Obstinancy & The American Dream

What makes you run?

Metaphorically speaking.

What's in it for you when the person running behind you sees the full soles of your shoes and your elbows catching air? And the person in front of you suddenly hears foot steps?

What would make you chase a goal so intently that the list of things you exclude to maintain your focus is almost as long as the list of steps to the end itself?

Why do you have no answer when someone asks "Is that fun for you?"

Have you been told that this choice is crazy?

The passion of relentless obstinancy cannot be understated.  There is no substitute for desire. You can't teach it, you can't coach it, but you can spot it in someone's character and hope that person is forever on your side. It's the intangible that no stat sheet can quantify.

A person who, in the balance of things, will tip toward personal achievement over personal comfort is infinitely more likely to realize long term potential. Success and pain are not typically considered in the same instance, but that may be because the former eclipses the latter with really good endorphins, not because the path was a climate controlled walk with well lit directional arrows.

Motivation can sustain a project when raw talent without motivation will fail. A motivated person who can ultimately claim domain expertise is potentially unstoppable, and domain expertise is part talent and part determination. Therefore it's anybody's bootstrap to grab.

And you thought the American Dream had drifted back into a deep REM cycle. It never went anywhere, it's just that recently we thought we had to be asleep to have it. Time to wake up.

So what makes you run?

#17. Housemates! The Senses Get Some O.T. Duty

As the Goddesses of Residential Affairs are laughing their respective tiaras off because they think irony is hilarious, I find myself sharing a large house with four men, each of whom at various times are also my patients for coughs, colds, and muscle strains. Nice and respectful guys, certainly. Armed, trained, disciplined and fit, all of this and more when they're out in their duty personae. These are the fellows you want on your side once you leave these thick T walls that encircle us like a massive corral in the U.S Consulate.

 But having spent the years since my brothers left for college not in the company of male housemates, as a matter of understatement, I do have some catching up to do on the other than subtle ways of this gender occupies space.

It's not as if men have not made great impact on my life and the way I see the world. I just haven't lived with them. We finished our shifts, or bike rides, or dinner, and went home. Different homes. Three consecutive decades, notably, included the preponderance of men named Jeff.  Jeffs that really made a difference. In the 1980's Jeff and I pedalled our bicycles around eastern Europe when it was still the "Communist Bloc" countries. In the '90's a different Jeff was the rural paramedic that had my exposed PA backside as a solo rural ER provider; he later became key to Peacework. Then in the early 2000's, another Jeff cajoled me to invest with him in a medical practice that would allow me have the financial freedom to administer Peacework the way I wanted to. He was right.

 But any one of the Jeffs, two of whom are no longer sharing this earthly plane with us,  would have enjoyed demystifying this current situation for me. With these housemates, for instance, I can usually tell where any one of them is, and what part of the environment they are stressing, using just any one of my senses. And  admittedly, my individual senses are not really all that keen. On the contrary, each of them seems unaware of, well, most everything that involves sensory perception indoors. The duality of their perceptive skills is akin to an on off switch. It seems once they are inside these friendly homey walls, the duty persona of trained and gritty professional degrades to somewhere between Homer (the American, not the Greek) and the Hulk.

Their language often includes entire paragraphs within which not one sentence would have met the criteria for inclusion on the airwaves of 20th century network television, and even by this century's standards, only scattered sentences would make it past censors, and probably not enough to make a sensible delivery of information. Yet, when on duty,  I hear them speak on the radio, and the words sound like they could belong to Anderson Cooper at a state dinner. And we know Mr. Cooper is not profane. Not Gloria Vanderbilt's child.

This is also to note that I've moved again. This is correct: no longer in a dry CHU, where 4 others could not possibly be with me, no matter what their habits and behaviors.

I need to update the folded napkin that I keep somewhere in a piece of luggage not checked or misplaced and update

The (***drumroll****)

Movement List 2011-2012:

Sept 5: Deployment Center, Ft Worth, TX
Mid Sept: West VA training
Late Sept Early Oct: Falls Church VAWaiting Period, Best Western Variety
Late Oct; Waiting Period, PHX Home Variety
October 28: Erbil arrival, first U.S. Consulate cubby living space
Early Nov: Second Consulate room above the clinic
Late Nov: back t the U.S. for mom's memorial service
Thanksgiving Day: Move to the desert Diplomatic Security Compound and first dry CHU; a 200 acre desert site, former forward operating base
Mid Dec: Slept in my office for 10 days. Long story unfit for this space; Santa did not find me.
Late Dec: Moved into a different dry CHU
Dec 30: temporarily back to the U.S. Consulate, a 1;5 acre site

Of Course it's Temporary. Eleven moves in 16 weeks would suggest a guaranteed absence of permanence wherever I've had breakfast. The first thing I'll do when I return in March after having a break in the US is move into yet another different CHU at the Dip Security location. However, I've only actually worked in two places: the Consulate and the Diplomatic Security Compound, so that at least has provided some stability during the packing and unpacking of things. And the basic anatomy and physiology of humankind hasn't changed while I was waiting for my bags to offload. So I'm good.

I've become familiar with my patient population, and the way things work and sometimes don't work here. If you've ever familiarized yourself with a workplace, it takes at least a few days to first learn the standard operational procedures during official orientation, then a few weeks to realize the substandard operational procedures that collectively function for a place in real time, then the next couple of months figuring out how to survive without making the gap between the two any wider. Finally, if you're lucky, you may have the chance to narrow the gap to make a more workable standard all around. I'm evolving into the latter phase currently, which has little to do with who is leaving breakfast dishes in the sink in my current homey homeplace and more to do with where the medevac helicopters are parked. And if the fueling site has quality fuel for them.

With the military departing, the opportunity for the aforementioned gap to widen is tremendous. With tensions in the country being what they are, we don't want that gap to be a place we are looking way up from wondering what just happened. SO we have our work to do here to prepare for and avoid disaster. It's not just treating upper respiratory symptoms, although that may feel like your personal disaster when you awaken with a pounding head and dry cough.

That's definitely a part of my job that I break away from to package the decongestants when when I look up from what I'm doing. It's not as if our guys can run out to the local pharmacy and stock their med cabinet; they are locked down on this compound and I have a captive set of patients. They only leave to protect a person they are here to protect, not to run errands. We all share the same airborne germs more or less too.

The URIs will pass with tincture of time, according to my clinical instructor in 1992. She knew what she was talking about. A bit more time sensitive, however, here and now is our ability to respond to a mass casualty attack or to an industrial accident of any magnitude. We talk, we plan, we package gear, we train, we review the helicopters and ambulances, and we live together and have every plan to continue this way unchanged and unscathed.

I think my housemates are happy. What would be a sign? If they are indiscrimimately noisy in ways I did not even know made noise, eating well according to the dishes in the sink, smoking plenty, profanely articulate, choosing to be delightfully polite to me, whom they cheerfully call "Doc"?

Is this a good gauge to go on with the male housemates? I'm enjoying them, honestly. What a novelty; it's like a crackerjack reach -inside -whatchagot just to go outside my door. I've never lived with my patients either, although we used to joke about taking certain ER patients home. Never lived in an armed frat house, never  made a mass casualty plan that included everybody I know and nobody I didn't, and never really knew I would never go barefoot ever for any reason in a house until now.

What a unique personal opportunity as this country continues to argue  itself into new unworkable corners. Sadly, the corners include sectarian violence as witnessed by the hundred people already killed in Baghad since the new year. It could also include a possible attempt at independence by this region, Kurdistan, with unknown consequences from the southern Iraquis. It is less and less likely to include a coalition government of the sects working together that had been the attempt of the US backed effort, and crumbled almost instantly upon the US departure.

Meanwhile, in another hemishphere just half a world away: Today is the second anniversary of the earthquake in Haiti. Je me souviens. I hope you'll remember the resilience of the survivors and the strength and love so many of you have shown to help ever since that day that life changed forever.

Since the moment the dust settled, the wounded and refugees needed homes, the orphans needed feeding, and by October the cholera patients needed care. Peacework Medical and all of you generous donors and volunteers have never quit.
We're going back again in July to Ranquitte, which is Peacework's home. We have 4 spots left for 2 docs and 2 PAs:
http://www.peaceworkmedical.com/    mesi mes amis,  je t'aime toujours  pb

#16. Rousing Chorus for Spontaneous Adventure

Adventure was never meant to necessarily have a beginning, middle and end with the chance of a podium appearance if it all went perfectly well. It was never intended to fit into plans, in fact conversely, plans were made to fit as the adventure unfolded.

You can have your contingency plan, your back up, your go-to if things go wrong as the adventure reveals itself within your plans. That's the very intrigue of the element. But the surprise, excitement, fear, joy, pain and sometimes disappointment that adventure brings just happens. Nature does a fine job of behaving in an authentic way. Your model and mentor is all around you when you go out to play.

But somewhere along the way, the sight of someone sipping Gatorade with a side of chips on the sofa became less visually stunning and more a part of standard living room cuisine. I will arbitrarily tag this as the point at which spontaneous adventure ended for most of middle America.

 We turned some proverbial corner and stopped playing outdoors, and it had little to do with age and something to do with being told to wear a helmet and pay an entry fee to do this as a group and pedal there in a line. Then stop there.

Alternately, at age 10, I was building clay, cow dung, and acorn dams in the woods, and being chased by the farmer with a 12 ga., which he did indeed shoot into the air, I suppose because the dams were so effective they were ruining his ponds. I had a step on him this one particuliar day, only to make it to the safety of my home to be met by my mom, who would not let me inside due to the products listed above that were all over me. She saw the farmer coming. She used a Hungarian word that she used in times like these, always in reference to things smelling bad or going terribly wrong. This was both. It certainly felt like an adventure as I started running again.

(editor's note: the word may have been southern WVA Hillbilly in origin, or a blend of linguistic adrenaline that included the Magyar Dynasty and Almost Heaven. I never could tell the difference, but I learned quickly enough not to use these words, or say things a certain way, if I intended to be understood by a classroom of my peers. I was sent to speech therapy in first grade. This lasted one session, and I assume it was determined I was just using a playbook of word choice and pronunciation that was not quite ESL before it had a name. I tried to sound like the others. I did. I do. And when I travel I can spot a central Piedmont NC accent by mid sentence.)

Since then though, adventure became packaged like a frozen TV dinner, albeit a manly size. You're supposed to know the contents before you open the package, as if you could read the label and know what you were buying or trying to achieve. The element of mystery, of beginning the day and not knowing what could happen, had passed as the default. I call foul on this. Yellow card.

 Instead, you are now planning to go on an adventure trip as advertised. How did this planning person know in advance what would happen? You can't subcontract this to someone like a deliverable due next week. Have I begun confusing adventures with agenda items? Big difference; and if so, I was in more trouble than that day with the farmer. I'm not sure how I would pack for such a trip of promises. Oh wait, there may be a required packing list.

 Then Gatorade developed a low calorie option, I suppose, for this sofa sitting purpose, since its original purpose was for avoiding dehydration for intense athletic events lasting more than 40 continuous minutes in humid conditions. I guess it's possible to dehydrate while watching TV and eating chips, especially if you live in the desert, but we can now rest easy this won't happen. Thank goodness someone in a lab was thinking of those of us in deserts who worry about electrolyte replacement while avoiding hyperglycemia.

The fear of the unknown is the element of adventure that makes it appealing, and it's the very thing that tests you, teases you, focuses you, and may make you come back for more. Or learn to stay away. You prepare for it. You train for it. You pack for it and repack for it.

Your imagination is given the keys to the kingdom, and for this you have to prepare your mind as well:

Fear of the unknown must be the most unrelenting fear  that we can give credit to our higher thinking. Animals only fear what they already know. Desire of the unknown must be the most unrelenting desire of our higher thinking. When these two are combined, for some the calling is transcendent.

How can you plan adventure? You just can't; you only plan for it in the same way you plan for best and worst case scenarios. You can only hope to meet it where it lives and be open to the possibilities in whatever environment you've chosen. Go where you are intrigued; its best habitat. It's your energy, your desire, your willingness to make what could be bad luck into a situation that challenges you. The outcome has as much to do with attitude as  skill.

  This day will be different from yesterday, that much is certain, and that's why you go. Imagination has been given a day to roam free, and possibility is never far behind. You may not even know you're having an adventure until you are immersed in it, this thing that has gripped you and makes you use your ability and mind and body to fix it, find it, wait for it, or out run it, whatever it is that has made your day come to this moment. But it has made this one different from all the others in some way.

And you will come back for more.