I didn't sign up to be a policy wonk

So, I am kind of sort of in charge while people are out on Christmas R and R. You have two choices here, you can try and do as little as you can get away with, which some people do when they get to the end of their contracts, "EOC" as we call it, or you can stay engaged and try and get stuff done. I am trying to get stuff done. We have two new docs at KAF and I am trying to use and abuse them to get policies written and make changes for the better.
We are the physical exam center or "PEC" for Southern Afghanistan. We are supposed to do 20 physicals a day for people who are renewing their contract. We can't do twenty because we are using the clinic and have people come in at 0500 before sick call hours. We have been fighting to get a tent to make it a dedicated area to physicals only. We finally got the tent and they have been working on it, building walls, etc. to make it a free standing facility. We went over their to look at it yesterday and after many hours of work they have built two rooms. One of which we can use as an exam room, so we have gained exactly nothing.  They have one huge room to weigh people and draw their blood. It is about 5 times bigger than it needs to be. And we have one room to do EKGs and one room with paper thin walls to be an exam. We asked the power that be why it was designed this way and the answer was "that's how the do it in Fort Worth." Fort Worth is a hotel. And it's in... Fort Worth. We are a tent in...Afghanistan. Also the construction work is shoddy at best. It looks like a 6 grader did it after a night of drinking. Where are my movie construction dudes when I need them? We will make it work, we always do. Why is nothing easy here?
We have had a couple of people stick themselves with needles here. That's not good. So, I decided that we need a needle stick policy because we don't really have one. We have some policies but they are vague and hard to follow, so I tasked one of the Docs to write one. He banged one out in a few hours and it was good. I made the mistake of sending it out for comment. It went from two pages to 20, then down to nine. Turns out that someone else had written one a month ago but it was given to administration, never to be heard from again. No one told me about it. Then we got into an argument about where to put commas. Instead of two hours to get it approved, it is taking two days. It has been rewritten many times. It's back to 9 pages. I just made some changes and wrote "approved' by me and sent it out. Except I forgot to attach it to the email. Like you've never done that. And I sent it out in the wrong format. Word, .pdf, what do I know? But it's out and I now have another headache, Oy.

I AM MORALLY BANKRUPT AND SO IS AMERICAN AIRLINES

51 Days and I am out of here. EOC. "End of Contract." Christmas day here. We are working half a day. We went to Christmas lunch together at the British difac. Americans and contractors first then they redecorated for the British forces. Christmas crackers everywhere. I used restraint and didn't steal one. It was tough. I wanted one bad. But, Santa, I was a good boy. Turkey and roast beef for lunch. Christmas pudding for desert. All very yummy. Ate too much, just like back at home.
The day before, I was on the phone with American Airlines. Dyncorp buys your ticket here and back. I asked to be routed through London so I could spend some time in Jolly Ole. I will fly E out for a well deserved vacation. So I have my locator number and I call American airlines. I just want to make a stop over from Dubai in London. Instead of 4 hours I want ten days. Sounds easy enough. But noooooooooo. I have to pay the difference in fares. Ok I'll pay the $150 for a change of ticket plus, wait for it, $4000K. Four grand to change my ticket! All I want to do is change one segment. I couldn't even find a 4,000 dollar fare on their website. I could buy a ticket for $900. I went up the chain and got a snooty supervisor. I thought his name was Clarence. Turns out her name was Claire. Oops. Did make my negotiating a little more difficult. I asked for an explanation. None forthcoming. I finally got her to admit that it was a wee bit excessive. The word "can't" was uttered many many times. She said if she did this it would get her fired. Alex was across from me with a suggestion.  Cancel the ticket and get it applied to the new ticket. So I proposed this to my new, still employed for the moment, friend, Claire. She was trying so hard to be unhelpful. It was Christmas and this is American Airlines and they have a tradition of uncaring to uphold, after all. "We don't care, because, we don't have to." Too bad Southwest doesn't fly to Europe. I hung in there with my suggestions. Apparently there was a molecule of reasonableness in my offer. She would check. She came back after an eternity of being on hold to tell me that she was still checking and to thank me for holding. I wrote employee evaluations. She was back. Apparently the American Airlines computer was sticking to its guns of non-helpfulness. Still holding, I wrote three evaluations. This is the key, have something to do while on hold. Build a house, read "War and Peace" or even negotiate world peace. Anything to stay on line with them. She was back. Success, but one problem. I had scheduled my flight to fly British Airways. Nobody wants to actually fly American, we just want the mileage. Of course, BA flys non-stop LHR to SFO. Not good ole American. We have to switch in Chicago. In February. What could happen? "Fine," says I. Book it Dano. Or Clarence or, whomever. It had been so long that I forgot her/his name. Got E a flight. Of course, because I am a dumb-ass, I booked the wrong dates. Forgot about that losing a day thing. But rebooked within 24 hours and American waved the booking fee and we are golden. And I did not spend 4000 dollars. It wasn't free by any means but to spend time in London with my honey? Priceless...

A typical day. Except for the benadryl.

One of the perks here is having your laundry done. Because it is Afghanistan, it is not without its risk, of course. Risk one is that you may not get everything back that you sent in. Risk two you may get more than you sent in. Risk three, they don't rinse out all of the soap. Risk four, your whites come back battleship grey.
E sent me a duvet cover awhile ago and it finally needed to go to the laundry. I picked it up two days later and put it back on my bed, just in time for the weather outside to dip down to the thirties. Comfy and warm in my bed I snuggled deep into the comforter and fell deep asleep. Until I woke up. Itching. And covered in welts. WTF? OK, I have to pee. Brrrrrrr. A mad dash to the bathroom and back and I looked down to see that I was clearly having an allergic reaction. It finally happened, I am allergic to Afghanistan. Luckily, I am a highly trained Physician Assistant and realized that I need Benadryl. Which I just happen to have in my shaving kit, just in case. Now, where the hell was it? Search, scratch, search, scratch. Here it is. Cool. 50 milligrams down with water and back to bed. Into a deep sleep. One of the lovely side effects. Woke up in the morning, all good. Except I slept through the alarm. Oops. Happened again the next night. I realized that there was still soap in the duvet. Luckily there are washing machines around here, somewhere. Some even work. We rent rooms at the hotel across the street from Camp Hicks and I found out that they have really nice washers and dryers. So I meandered over there, acted like I was staying there and rewashed the duvet in plain water. All is good. No more itching. No more diphenhydramine. Ok, I wonder what else in my room will try and kill me? I'm talking to you, pillow case....

Call me an ambulance! OK, you're an ambulance...

It is getting colder here. It was 27 last night. And the power went out. Hence the heat went out. Brrrrrrr. Thank goodness for my comforter. Back on this morning. Note to DYNCORP: You gotta put Mr. Diesel in Mr. Generator...

The Pakistani border is still closed. We are wondering when we are going to run out of food and fuel. Food, they can put in an airplane. Gas, not so much.

I was at the Role 3 meeting when I got a call about an eye injury involving a power tool at the clinic. I talked to the folks at the Urgent Care clinic, now the "referral clinic," and they said to use the base ambulance, because they can take people straight to the Trauma Bay. When I drove back to the clinic I was informed that that had already happened. So we waited, and waited, and waited. No ambulance. WTF?  We have a radio that talks directly to ambulance dispatch, so I called them. They had no ambulance request. (Turns out that we had called the wrong number. Our "911" is a 12 digit number.) So, I made a request for an ambulance over the radio.I had to use our ambulance's call sign to make the request. An ambulance calling an ambulance. The dispatcher was a little confused. Don't we have an ambulance? Yes, we do, but I need yours. Ok, they'll send one. The crew arrived, just a little confused, especially when they had to walk by our ambulance parked in the driveway. But they were quite nice and took our patient. Probably because the crew was Australian. Americans would have bitched and complained. Not the Aussies. Just came, took a look at the guy, packed him up, and left. Fair dinkum, mate.

Where's Waldo?

The dogs of war, literally..

Afghanistan has one of the highest rabies rates in the world. Probably because there isn't one rabies vaccine for dogs in the whole country, except for military working dogs. There is a very strict no pets rule here but it doesn't keep people from feeding feral cats and dogs. People love their animals. There is a poster that we posted that shows a cute puppy. That has rabies. It doesn't have to be Cujo to be dangerous. Everything here is trying to kill you, including a cute puppy. Who let the dogs out? In Afghanistan, Satan, apparently. We had a worker who was accidentally bitten by a dog. Poor guy, his job is to dump the garbage at the garbage dump at one of the fobs and he was doing his job when a dog just walked by and suddenly turned and bit him on the leg. Rabies ain't no joke. Only three people in history have survived rabies. There are two types of injections that you need, a "Rabivert" which all of our fobs have and HRIG. HRIG is about $1200 a pop so it is only available at Role Three's. Like ours. This guy was out of our area but, because of the way flights are, we are closer, logistically. We could either medevac him here or send the HRIG there.  So I went down to the R-3 and pleaded my case. No problem, I was told just fill out the paperwork. Paperwork? Of course, it is a military hospital. While I was waiting, one of the bomb sniffing dogs was hanging out in the hospital with his handler.  He is a sweetheart and loves to be petted. He really should be a therapy dog. We have a therapy dog, but all the handlers agree that he is "useless." He is a big lazy black lab. "Igor" on the other hand, is a young bouncy Shepard mix. He even knows how to pose for pictures. Looks right at the camera. Ears up, adopts cute puppy look. He is super smart. And a handsome boy at that. His handler knows how much people miss their dogs so he brings him to the Boardwalk and other places so people can get their "puppy fix." Igor doesn't seem to mind at all. Beats sniffing out bombs.
 So there I was, petting a dog, in a trauma center, waiting for a rabies vaccine that I had to give to one of my Medics to fly to a fob for a guy who was bitten by a dog.
Yep, just another day in Afghanistan. Woof.

Step 2

Later I got a call from one of the other hub PA's about a guy who has a nose bleed that won't stop. He is on a blood thinner that he isn't supposed to be on, but he had made it around the entry physical and snuck by us. Now he has a nose bleed that nobody can control. He went to a Role 2 and had 2 "rhino rockets" placed in his nose. They are basically catheters that have balloons and a tampon on the far end that blow up to stop posterior ( way in the back of your nose) bleeds. They were sending him to us to find him an ENT doc to fix his nose bleed. He arrived later looking like a character from Star Wars. Actually a real war because his shirt was covered in blood.I explained to him that his nose may be bleeding because of his blood thinner and that he needed a blood test. I also explained that there may not be an ENT doc at the Role 3 and he may need to go to Dubai or home to the US. "Just send me back to my fob." he said. I explained to him that we couldn't do that because of his epistaxsis aka nosebleed. "I ain't going to Dubai, I hate Arabs," he said. I explained that we would send him to the Canadian hospital. "I'll just wait for my R and R on the 19th, then." No you won't. You'll bleed to death by then and you can't keep those things in your nose for 9 days,  you dumbass. Ok, I didn't actually say that, I just thought it. I went down to the Role 3 and asked if they had an ENT doc. "Negative," was the answer. I went back to my patient and explained that he has to go to Dubai. "Nope, I ain't going, " says he. I explained to him that he would have to move up his R and R and leave on an earlier flight. This took a good 20 minutes of explaining. I actually had to tell him that I was making him go home. More emails and phone calls. I wrote up his consultation letter and mad copies of all the pertinent paerwork and arranged for someone to take him to the travel office and get him a place to stay.
We were on top of the clinic watching the lunar eclipse when we got an ambulance call.You guessed it, it was for him. It turns out that he never changed his shirt or washed his face so the manager thought that he was bleeding to death.We checked him out and sent him back, to leave on the 0600 flight out of KAF.
The next day I went to get my appendectomy patient out of the Role 3 and take him back to his room. And who do I see? Nosebleed guy. Wandering around. I didn't give it much thought at the time, but...
I went to lunch and when I came back one of the Medics asked me,"Guess who's back?" "You are kidding me, he was supposed to be on a flight." I walked into the room and realized that not only had he missed his flight , he had pulled out his rhino rockets and was now bleeding all over the place. Dennis was in the room valiantly try to stop the bleeding. Unsuccessfully, I might add. While our new Doc squeezed the dumbass's nose together, Dennis went down to see if he could get some new rhino rockets. Turns out that our Role 3 doesn't have any, but they have foley catheters and nasal packing. Doctor B volunteered to repack him. I stayed out of the room. For fear I may kill his dumbassidness. I offered moral support and all that and poked my head in to see if I could do anything to help. Before anyone could answer, I closed the door. I'm helpful like that. The room looked like a slaughter had taken place. Took awhile to clean it up. We sent our patient back with a stern warning not to touch the packing in his nose. Emails and phone calls started flying. He needs to be out of here now. I offered to buy his ticket and drive him to the plane. Seriously. 600 dollars well spent. "No problem," said our travel and HR department, "we'll get him out of here." "He'll need a babysitter," I told them. "and don't let him pick his nose." He probably won't even change his shirt. We all imagine him wandering around the Dubai airport like Tom Hanks in "Terminal." "Mr. Dumbass, white courtesy phone. And try not to bleed on it."
Reason #2 for my migraine...

Yes, I'm slacking...

I had a migraine headache and it slowed me down a bit but I'm back and thanks to drugs and osteopathy, I am better.
So here's what's happened while you've been gone (where were you , anyway?)...
I got a call about a patient who was being sent to the Role 3 as a medevac for "a little chest pain and shortness of breath." No big deal. He was coming in at 2300 so I went to bed with my phone next to the bed. I figured they could call me if anything happened. I woke up, checked my phone and no call. All good. Around 100 I got a call that he was "ready to be picked up." Cool, I thought. I will toodle on down in the forerunner and pick him up and bring him back to the clinic, read his chart and ask him if he wanted to go home. I walked in to talk the the  PAD (admitting corpsman) who was gathering his stuff for me to take with him. As I was talking a doctor tapped me on the shoulder to ask me if I was here about Mr. X. "Yes I'm, " I said. "Ok, well he's intubated and has been given thrombolytics because I think that he has had another pulmonary embolism. He's still unconscious. Would it be easier for you if we tried to extubate him?" Um, you mean to get him into my SUV? Ah, cause I didn't bring a ventilator. Maybe if I drove with the windows down...
Turns out that, as they said in "Cool Hand Luke," we had a failure to communicate. He needs a medevac. Quickly. One with a bunch of fancy medical stuff in it. And a doctor, nurse, respiratory therapist. You know, the usual. "I'll be right back," I told the doc. I went down to the ICU and there was Mr. X. Not looking so good. I told the nurse not to extubate him (pull the tube out). "There's no way we're doing that," she said. I love ICU nurses. Literally. So off I went to start writing emergency emails. I told the staff at the clinic my story and that the docs will have to cover for me. No problem. They are great at pulling together and working as a team when they have to. So phone calls were made, emails were sent. Updates provided. Many trips back and forth to the Role 3. The pt.left at 0200 that day. He is in Dubai and actually doing better. Step one of why I had a migraine.

Never a dull moment

We have a new doctor, Alex. He's from Maine and is another DO. I am trying to train him as Larry, our Medical Director, is going home for Christmas. I am trying to show him the ropes, but the ropes here are not like ropes anywhere else.
Anyone who does medicine will tell you that one of the coolest feelings is when you come up with a difficult diagnosis and you are proved right.  We will also tell you that ya can't gloat because for every time you are right, there are three times that you were clueless. But, I couldn't help myself. A patient came to the clinic and the Medic told me he was stumped. He had weird abdominal pain and I poked on his belly and thought that he may have appendicitis. I ordered a complete blood count and he had an elevated white blood cell count, indicating that something just wasn't right. So off I went to the Role 3 to present him. The accepted him and I asked them to do a CT scan. I went back later to see how he was doing. The NP there didn't feel that he had appendicitis. And had decided that he didn't need a CT scan. "based on my clinical judgement," he said. I bit my tongue. They do us a favor by doing CT scans. No sense in pissing him off. I was bursting at the seams. "What clinical judgement?!" I wanted to yell. I thanked him for seeing my patient. I told him to call me when he was ready. We then started talking about all of the weird diagnosis we have had since we've here. I was fuming as I drove back to the clinic. His last comment was,"well the CT scanner will always be here if he gets worse later on." Ok, he was no longer my patient, but all I wanted for Christmas was a CT scan of his belly. No worries. I will deal with it. Maybe I'm wrong. Later on, I realized thatI hadn't heard from them, so I sent Larry down to pick the guy up, because I was busy in the clinic. He drove down there but returned without the patient. "Where's our guy ? I asked. "In the operating room, getting his appendix out." He said. I couldn't help myself. I jumped up and gave myself an imaginary high five. Even a blind squirrel finds a nut now and then. Turns out that his appendix had slipped up and behind another organ, giving him an unusual presentation. I guess sometimes the voices in my head are right. Sometimes...

Stuff...happens.

The advantages here are few and far between here but there are some. One is "free mail." No stamp required for mail back to the US. So, channeling my inner Maurice Caplin, I have been doing Christmas cards. There is also the British Post, where stamps are 75 cents and the mail gets to England quicker. It is a good thing that I had something to do. Our IT department was "improving band width" and shut down the internet for 4 hours accidently. So no internet, no phone and no printer. No problem, I just did my low tech Christmas cards. I also bought a tiny battery operated Christmas tree for the clinic and, for equal time, a menorah. Ok, not a real menorah, a gift bag with a menorah on it. Which I taped to the wall. Probably a bad idea to light it...
We had a rocket attack last night at 0200. We received the "all clear" at 0202. Didn't even make it to the bathroom. This is my kind of attack. I wonder if someone leaned against the button? A "butt dial" rocket attack...
We had a new doctor arrive here yesterday. Dr Sharp is off on a mission and everyone is freaking out because we have a new Doc. Calm down people, we don't even have an office for him yet and I'm sure he is in the "what the hell have I gotten myself into?" mode still. I just shook hands with him and then he was whisked away by Admin. Wonder if he saw my tree...
I went over to the British compound to listen to two nurses from the Role 3 who were going to sing. They decided to set up outside instead of inside in the theater. The warm theater. It was mighty cold outside and they were giving it their all. My little sweat shirt was not quite enough, so I bailed pretty early. Gets cold here in the high desert at night. I can here the heater in my room kick on. I have set it to 22. Not sure how much that is in Fahrenheit. It's either 76, 106 or 36. Never was that good at math...

"Happy Birthday to you, Happy Birthday to...hey wait, where are you?"

Today is Kaki's birthday. We can't sing to him because he went on a "medical mission" with Dr. sharp et al out to a fob to do physicals. They should be back in a couple of days. The clinic is down to a skeleton crew and it is very quiet. We have new people in training, people coming through on R and R and people who have quit and are leaving. Every morning at morning report you just never know who's going to be there. The numbers range from 25 to 5. We just keep plugging along. We had to to babysitting duty at the Role 3 for one of our patients until we got her medevaced. The "sitters" had to be females, so that reduced our crew a little, but as Zee says, "we'll just kick ass as always." There is a 6 month old baby there that everyone has fallen in love with. She is one happy baby and loves everyone. They have made a crib for her and she has about 100 adopted aunts and uncles there. Including our Medics. I walked into the Ward and there she was in the arms of the Master Chief of the Command. I think he was going to draft her, so she would never leave. It is so uncommon to see children here. Especially a cute young smiling, uninjured one. So my babysitters did some babysitting while they were babysitting. Only in Afghanistan...

"rocket attack, rocket attack...ouch...ouch...oh, never mind."

Karki and I were driving home from clinic and decided to get something to eat. So we were driving down the road we found that it was blocked by a truck so we went down another street to another difac. After dinner we took the back way back to Camp Hicks and heard  the rocket attack alarm. We rolled down the window, heard a "boom" and the alarm reset and go off again, so we bailed out of the truck and headed for a bunker. It was dark and we were in unfamiliar territory. As we ran towards the "bunker" I turned on my flashlight at the last minute. It wasn't a bunker, it was a concrete structure to hold up a big antenna and it was surrounded by barbed wire. Oops, this could of been ugly. There were some other guys standing beside it, so we joined them for awhile, then headed back to Hicks. Another boom. Another alarm. We bailed out again. We realized that we were in front of the gate, so we made a pit stop at the bunker of the hotel across the street, waited. No more booms, so we headed into Hicks to "our bunker." Just as we got there, the "all clear" sounded. We had looked like John Belushi in Animal House" making a serpentine through the CHU's. Like the rockets would be fooled. Actually it was just a couple of fools trying to get home from dinner. Only in Afghanistan...