#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.