#6. That Light Looks Green....

Security clearances are not granted for any of the same reasons one may have achieved a parking spot under the awning at work ( which is the peak of the food chain in PHX). However, it was only with tremendous patience and professional reserve, that a Special Investigator endured what no man before him has ever done: he reviewed, in detail, the purpose and activities of every international trip I've taken in the past ten years. Nearly every one of these was because of Peacework Medical Projects. He did this in person with only cold water and fruit to sustain him. It took two and a half hours.

He never lost focus, but somewhere along the second hour he did seem to become a believer in the work that Peacework accomplishes. I appreciate this immensely. Not only did he accept that the work is credible, accountable, and consistent, but his expediency has hastened getting the necessary credentials to go to Iraq.

And the sooner I get there, the sooner I can set the dates for Peacework's summer 2012 efforts in Haiti. And that will be another foreign trip to explain to a future special investigator when the time comes to renew my security clearance...and that too will be special. Not spectacular, just special.

Peacework is worth the trouble. All of it, every time. It just comes in unlikely presentations some days.

It would appear that my next post will be from the Syrian Desert.

#5. Holding that Thought in my Home ER

My Home Base ER, the one I've called my own since 1999, is a special place. It's not just that I'm biased toward this irreverent, remarkably capable, uniquely challenging hotbed of mixed pathology and sociology. It really is special.

 While waiting for this Iraq contract to fall into place, I've returned for a few shifts of the experience at "The 'Vale".  We know it, love it, and sometimes less than love it, and we are fond of saying "Only at The 'Vale".

There's a reason this phrase has become commonplace. There is a reason this phrase is accurate. It seems that for every set of hoofbeats, there really is the occasional zebra, and the zebra may sometimes have a peacock riding in on its back. And the peacock may be playing a bagpipe.

Unfortunately, there is no zebra specialist on call for us. Anywhere. And no one will even discuss accepting the peacock problem without a zebra consult. The conversation ends each time before you can bring up the part about the bagpipe. (What's the bagpipe about anyway?)

This is only a part of what makes the 'Vale team so good. We overcome. Just get the zebra and peacock separate beds and figure it out.  Put the bagpipe in a belongings bag for later. The  translation phone, of course, get that out again, because this is not going to be our common language here, which is Spanish.

The peacock refuses a bed, thanks, just wants her oxycontin refilled, and a different ride home if we're keeping the zebra.  The zebra, being a zebra and not a horse, is mysteriously ill. He is his own worst historian, as if he just looked in a mirror this week and realized he was covered with alternating black and white stripes.

More hoofbeats. Horses this time. Herds of them. It's the bread and butter stuff of the ER: sore throats, lacerations, headaches, mental health crises, sprained ankles, chest pain, skin abscesses, abdominal pain, difficulty breathing, bleeding during pregnancy, drug overdose, skin rashes, fractured bones, the occasional gunshot wound, car accidents...pain, pain, pain in every way the body can hurt.

Our nurses triage and manage the flow and flood expertly. Every patient and every family gets roomed and ready to be seen by a physician or PA in a series of movements that is a coordinated dance. It may appear chaotic. It may sound noisy. But there is a willful system that functions gracefully despite superficial appearances.

Some come by ambulance to this Level II trauma center. Some come by private vehicle, and these drivers just do not check on the trauma level of the 'Vale before transport, which is why we sometimes get major trauma from the streets. This ER is a place to stabilize such a patient for further transport. Our docs do it best. Probably because they get plenty of practice.

So what about that zebra? A thourough work up was completed. With stripes growing more and more pale, he was admitted to the ICU with an anemia of unknown origin.  Lots of work to be done for his ailing animal. The ICU RN calls back to ask how we attached the nasal canula.

The peacock's pain was treated at the visit, non narcotic Rx, follow up provided, and no taxi voucher from the charge nurse. She found someone to come give her a ride. Unfortunately, there was not a chance to see which species arrived. Too busy. Hoof beats pounding.

It's noisy at shift change. There's an IPod that just met two extra powerful speakers. A patient has found the volume on the Sponge Bob channel. (He needed a chair for this.) Nurses are huddling to round on which patients are where, who is in transition, and who needs what care. They probably discuss other things too, but that's what I can relay here.

Then I hear above all of this from a registration clerk, as she pulls her chair under an open desk, "Hey, who left their bagpipes here?!"

#4. And Hold That Thought

This desert is so familiar.

 It's because the dust in the air making these stunning sunsets has risen from the valley of my adopted home, the Sonoran. It's an exotic desert alright, it's just that it's my local exotic patch of sand. I didn't travel to the other side of the earth for this dust storm.

The fact is this: I've been sent on a loop back the The Central Desk (aka home)  on my way to Iraq, expressly with the directive to wait. This could be a testament to our government's prudence when issuing security clearances to the individuals in a group such as ours, or it could be a testament to, well, the simple slowness of things. Either way, I have a happy dog underfoot and some well fed friends with whom I'm enjoying another round of hello/good by/for the interim.

This is an edict to live in the moment. I could be told to leave any day, and since my bags are not exactly re-packed, there would be some urgency at that point. Accordingly, there is no reason to begin any new projects here at home...I'm reluctant to even stock the fridge. Then, on the other hand, there is no way to know how long this could take. It's not as if the people who work one's security file have a tracking number for checking its status.

So here in the moment, where I am living, there are details to be appreciated. At sunrise, the water from the neighborhood park sprinklers is actually cool. This is a phenomenom not to be missed after a summer in a place where heat is not just for conversational purposes. The sprinkler water temp changed during the 20 days that I was away, having been tepid when I left. There has been no rain to speak of all summer, and the feral cats sneak out from their lairs and drink when the sprinklers stop. My dog Lucy respects their space; I instilled this in her for her own well being.

Homeless men and a few women sleep in my neighborhood park too, and are usually just waking up when we arrive. They are friendly with me and Lucy. A couple of Native American men pretend Lucy is theirs and one calls out joking  "hey, why you got my dog?" and gives her a hug. Another man talks loudly to himself most days, but waves hello on the mornings he notices us. A few people remain sleeping, bundled in a blanket or just a t shirt and jeans. It's not as if it gets cold at night yet.

 It's the same small crowd predictably on these 2 acres, which converts to a family oriented softball/football venue in the evening. These families seem oblivious with whom they are sharing their experience with in the dark perimeters of the park; they pack their minivans under the stunning bright glow of the field lights when the games are completed, and drive to their homes with their dusty cargo.

I appreciate the mixed use nature of my little urban park. City planners don't draw it up this way for 24 hour overlapping services. Social workers don't fight for funding so that park benches can shelter the homeless. Mental health advocates would likely not have outreach for this man who needs medication for the conversations inside and outside his head. But it's all in working order here near the Central Desk.

As this evening's dust glows bright orange, all the characters are in our places in this desert we each claim in our own way....even as one far away is calling me to come see. There is a world between the two, but I'm guessing that thirsty cats, orange sunsets, and individuals who are characters to behold prevail in both dusty places.

#3. Transition

In reference to that previous post about the opportunity to build confidence, this is nothing more than a metaphor for meeting challenges more frequently than being crushed by the same. Accordingly, there is no certificate of completion when you've passed the quiz; it's just that one day you realize that you're explaining the most recent quiz to people around you, and at about that same time, the questions get more difficult.

What made me think I could manage the medical needs of the men and women in a desert I've never seen on the other side of the earth? Was it the same sort of thinking that entered my mind when I opened a National Geographic and envisioned a reason to at least temporarily avoid the completion of my Master's thesis in Exercise Physiology?

 The year was 1986, and the concept that any true challenge is an opportunity to excel was in full force. I was preparing to sleep on my sister's couch and found the National Geographic with a center map that showed a thin blue line tracing all the way through North America beyond the Arctic Circle by way of the Canadian Provinces and Alaska.

My head almost burst from the size of the idea hatching inside: I would pack my bicycle bags and ride those few thousand miles to Anchorage and then to on the Arctic Circle. I had already pedalled across the US this way - how hard could another leg of the continent be?

 But what had made me think I could ride my bicycle across the US?  It was a history of assembling new bicycles in a neighborhood shop for a buck per hour under the watchful eye of the owner, until I was capable of learning repairs as well. Subsequently, periods on the side of the road were never a crisis; they were often a time for a snack as well as much as a repair. Perspective and carbohydrates help with everything.

For much of the 1980's, circumstances had dictated that I never lived with running water, electricity, or central heat all at the same time, although there were always one or the other, and this was the accepted baseline of comfort.  Classes at Carolina and then Virginia Tech offered not only higher learning but also hot showers and endless clean little white towels. Perfect.

When living at home is a lot like camping,  and getting to class is a lot like a bike ride, then an actual bicycle expedition becomes an extraordinary bonus to your daily life. Of course I would ride my bike to the Arctic Circle. Of course some days in the springtime near Denali National Park would not reach 32 F. It was not terribly unlike Blacksburg, VA on any given day in any given March.

When the aforementioned e mail came to me in a tent in Haiti this August, I could not have been more comfortable if it had found me in a Dial-a-Bed with a memory foam pillow. The two jobs, the one I was doing and the one on my Blackberry, presented both symmetry and contrast, with years, miles, and patients separating the two with a stories to be told and those yet experienced.

# 2. Transition

With all due respect to the citizens of Falls Church, VA, I am in the Twilight Zone. I'm not at home, and I'm not at work, and I don't know when I'll ever be at either one again.

I'm in a government issued, government funded waiting period. This is  expected when the Dept of State must issue a secret security clearance before sending  anyone to a secure workplace abroad. It just takes awhile.

 How long? Well, the weather is beginning to change here, and my Phoenix blood is needing warming measures already.  Some of the oak leaves are losing their summer brilliance, but have not fully accepted the colors of autumn yet. The weather change came on suddenly with a cool, welcome rain two days ago, and it never returned to its original warmth. My Sonoran desert mind had a brief thought of gratitude for the drops, forgetting that the neighbors here were still dealing with flooding and mold  from the recent Hurricane Irene.

So I've dug into my packed gear for the technical layered clothing sometimes known as winter wear. It's fifty degrees fareinheit, but it's a damp cold. I hear it snows in Kurdistan. There is snow in the desert. Nature has her way of keeping us interested with a nice paradox every now and then. We just have to get out and find these whimsical treasures.

But is the occasional discovered paradox enough to leave a comfortable home, wonderful friends, and meaningful employment, for what is described as "an austere, potentially hostile work enviroment" where protective troops are departing as we are entering? (Could I just get a National Parks pass and an all seasons tent??)  And at the same time, foregoing personal independence to live on a secure compound, when personal independence is possibly the thing I hold most dearly next to my furry canine, whom I'm also leaving behind...

What's the motivation?

The casual observer would say it's the money. Yes, the contract pays exceedingly well. But this observer doesn't know my history, since I've worked for a fraction of this pay (as well as for no pay at all) in other countries.

The only person who can fully explain this is currently at this keyboard. Importantly, the explanation is equally intertwined in how I came to be qualified and called for this position in the first place. It's probably a life story. I hope I'm not in Falls Church long enough for all the details...but some of the tales can be told in the pages that follow.

In some ways, an "austere" approach to clinical medicine was the result of a sometimes spartan approach to the practice of daily living, long before I picked up a stethoscope, and certainly after. Resourcefulness, frugality, ingenuity - these are all things that you rely on when a home or clinic's working goods are limited. You make do, and sometimes the outcome is as good or better than when resources are flowing. The critical element that can't be sourced otherwise is confidence. It grows, and you find yourself taking on the next opportunity.

The habits carried over seamlessly into third world countries, albeit with some careful dressing for US domestic application. But if a job description could be written with a person in mind, this particular one could be it. The written description actually followed the offer in this case.

It was not a call, actually, it was originally an e mail, and I was relaxing in a tent in Haiti, thinking about patients nearby in a cholera isolation tent. My Peacework Medical volunteers were scattered after the clinic had finished for the day, having seen over 300 local people for various ailments and a range of acuity.

 They are amazing, these volunteer teams, (http://www.peaceworkmedical.com/) who for two weeks at a time they bring health and hope to those who would otherwise go without. In this enviroment I did not open the e mail. In fact, I did not open the e mail for over a week, hence the call later. My Peacework Medical team and the patients there in Haiti were my first priority.