Discussion in 'The Lounge' started by Lightning's Girl, Jun 26, 2008.
The magnitude of the sacrifice that others make in service to their country.
David V. Cossman MD.
About a year ago, I opened an e-mail from EKalata@vascularsociety.com thinking it was just another blast to the Society of Vascular Surgery (SVS) membership regarding the vascular surgery issue of the day. Instead, it was a request from the U.S. Army, which had contacted the SVS to request help from volunteer vascular surgeons. The war in Iraq had depleted the domestic supply of active-duty vascular surgeons and volunteers were needed to cover U.S. Army hospitals until the Iraq hostilities ended or calmed down. Without really thinking about it and without talking to my wife or partners, both of which I should have done, I replied yes and clicked send. I will explain later why I was so quick to volunteer. Originally, I was told that I would be sent to El Paso, Texas, or Washington State, but somewhere along the way the army changed its mind and sent the civilian volunteers to Landstuhl Regional Medical Center (LRMC) adjacent to Ramstein Air Base in Germany.
Landstuhl is the major evacuation hospital for Iraq, Afghanistan and Kuwait. Major vascular injuries are addressed down range or in theater and then sent immediately to Landstuhl for follow-up care before being transported back to Walter Reed Army Medical Center or Brooke Army Medical Center (BAMC) in the United States. It is not unusual for a severely injured soldier to be stabilized in Iraq, transported via C-17 cargo plane to Landstuhl for additional surgery, and then back onto a C-17 bound for either Walter Reed or BAMC, all while intubated and all within 48 hours.
From a vascular surgical standpoint, this assignment is the kind of work that most vascular surgeons my age try to avoid. If you're looking to be regaled with surgical exploits in this article, you are sure to be disappointed. The surge in Iraq is working so the number of wounded soldiers brought to Germany has mercifully decreased, but even at the height of the conflict, a volunteer vascular surgeon could leave loupes at home to do the kind of work needed at LRMC, where massive wounds are washed out and debrided in the operating room (OR) and vascular grafts implanted down range are checked for patency. Occasionally, a graft requires revision or ligation if a limb is beyond salvage. During my two-week tour, more than half the admissions had at least one major extremity amputation upon arrival. Vena cava filters are the only endo work done there, so my limited experience with advanced endo work remained a secret.
In addition to the soldiers , many of the patients at LRMC are foreign or domestic contract workers injured down range or are military retirees living on or near the clustered bases at Landstuhl, Ramstein, Sembach and Vogelweh. Problems one would not expect to see at a military base like spontaneous carotid dissection, femoral artery thrombosis after a long flight or mesenteric venous thrombosis were nontraumatic vascular injuries that came in on my watch. Such patients don't stay long at Landstuhl. Because the army does not like to tie up resources with these types of problems, these patients get shipped out quickly to the University of Hamburg or to Walter Reed or BAMC in the United States.
To my surprise, the SVS sent a press release to the local media in Los Angeles announcing that I had volunteered to serve for 16 days in Germany, and within 24 hours I was getting phone calls from local newspapers. Cub reporters were showing up in my office to take my picture for local-niche rags that I had never even heard of. Graciously, the SVS office sent out these press releases for all volunteers to help compensate members for time lost from income-producing work. At this point in my career, my comings and goings create nary a ripple, but I appreciated the thought behind the SVS effort It was a nice touch.
I suppose this would be a good time to explain why I volunteered, over and above getting out of going to the Edelstein Bat Mitzvah. When it came close to the time to go, I had second thoughts because my 94-year-old father was sick, my kids had issues, and my wife, always supportive, secretly thought a nice check to Wounded Warriors was a perfectly acceptable way for a 63-year-old man to express his patriotism. Even the dog sulked. With e-mail and cell phones, however, you're never really disconnected and you can get back in half a day if needed.
In retrospect, I think there is some background information to explain my impetuous decision to volunteer. I signed up for the Berry Plan in 1972, which gave me a guaranteed deferment to complete my surgical training in exchange for two years active duty when it was over. At the end of my fellowship, the Vietnam War had ended and the army didn't need vascular surgeons anymore, so I was assigned to the reserves for six years.
After basic training in San Antonio, I had tough, two-week annual summertime tours, like Letterman Army Medical Center in San Francisco where I did a few carotids with the fellow when I wasn't having a beer in the bleachers at Candlestick Park.
As the years passed, however, I began to regret my military resume didn't match my outsized patriotism, and I welcomed even a meager opportunity to catch up a bit. This tiny tour of duty, however, only emphasized for me the magnitude of the sacrifice that others make in service to their country. It also laid to rest the popular portrayal in the press of soldiers as being dead-enders with no other career prospects. For the life of me, I can't understand how investigative journalists appear blinded to the extraordinary courage and patriotism prevalent in our volunteer army.
Mandatory military service should be required if for no other reason than to personally acquaint the rest of us with some of America's finest men and women. Maybe a little something would rub off.
For many of the soldiers I met on the base, joining the military was like entering the family business, where many before them had served for generations. For others, the military made economic sense because of free educational and career opportunities with good benefits and early, well-compensated retirement. Many enlisted as unadulterated expressions of patriotism. I didn't meet any refugees from real life in need of personality reconstruction. The army doesn't want reclamation jobs. Most agreed that a sense of service to country was a necessary prerequisite to endure the sacrifices inherent in military life. If leaving for a few weeks made me a little uneasy for a variety of reasons, I could just imagine what it must be like for a 22-year-old to leave a wife and young baby for the uncertainties of war.
In uniform, members of the military cannot engage in political discussions, but in civvies, I got an earful about the actions of the San Francisco City Council that banished ROTC from the city, or the legislative initiatives of certain congressmen who claimed to support the troops while proposing legislation that would compromise their safety by cutting off funding for the war. A common theme I heard was that one's position on the Iraq War or President Bush should not affect unconditional support for the military.
Most felt that Abu Ghraib and well-publicized but sporadic abuses of the Quran were not representative of the military's commitment to decency and humanitarianism that were ultimately necessary to consummate a lasting military victory. A chaplain with whom I spoke told me that enlisted men and women feared rebuke by an ungrateful civilian population almost as much as physical harm, and that for many not mercifully preoccupied with permanent injuries, coming home to indifference or repudiation caused lasting psychic injury. The army arranges for economy airfare to Frankfurt and commercial ground transportation to the base. I reported to Gate 1 as instructed but was denied access to the base because my orders were dated incorrectly. After a 15-hour trip, I waited while my little problem moved up the chain of command. Finally, the commanding officer of the base showed up to let me in.
An older fellow in civilian clothes who looked vaguely familiar was watching all this from the other side of the gate. He didn't say anything until I got in and then asked if I was the vascular surgeon. He was Don Trunkey, the well-known trauma surgeon from the United States. He was in the middle of a one-month voluntary tour. Whatever delusions I had had about my role at Landstuhl, it was clear I wasn't going to be the go-to guy on the base with Trunkey around. No matter. He was a delightful guy and I learned a lot from him. If you haven't heard his lecture on the medical care involved in the four U.S. presidential assassinations, you're missing a real gem of medical history. One of the most interesting activities was the weekly video teleconference that linked Walter Reed and BAMC with LRMC and the down range hospitals in Iraq, Afghanistan and Kuwait. If you're making rounds at your local hospital and you find an empty bed, chances are your patient is in x-ray or having a cigarette. At LRMC, an empty bed usually means your patient is already 6,000 miles away at the next level of care. LRMC has four flight surgery teams that move critically ill patients on portable respirators back to the States three or four times a week.
Going to the flight line at Ramstein Air Base to watch patients coming in and going out on giant C-17 cargo planes that can carry three Abrams tanks or three critically injured GIs is a highlight of the trip and provides some insight into the unique expertise the military possesses in moving human and material assets safely around the globe. Getting a patient from the emergency department to the OR in a civilian hospital seems to be more difficult than the seamless movement of injured GIs from the pavement in Basra to the intensive care unit in LRMC. We in civilian life could learn a lot from the army's expertise in logistics and its obsession with keeping everything in working order.
There was plenty of downtime to watch TV, read, write, e-mail, exercise and explore. By the second week, I had to confront the most dangerous part of my mission made them look like pedal pushers. I also did my own cooking in my little kitchenette in my room at the Air Force Inn on base. String cheese wrapped in lightly toasted Wonder Bread was a delicacy, with spice drops for dessert. If it's possible to get scurvy in two weeks, I was well on my way.
Operating rooms are operating rooms, but I couldn't help noticing a few differences between civilian and military surgery. In general, surgery and the military are a marriage made in heaven because both are grounded in the same principle of unwavering focus on the mission at hand. One would think that exsanguinating hemorrhage would get anyone's attention, but civilian ORs have become a circus of distractions that require increasing doses of equanimity to just stay focused on the job at hand. Working in an OR where everyone was focused on the same thing was like a trip down memory lane.
Perhaps the biggest difference between military and civilian surgery is the unique relationship between the surgeon and the injured. In civilian trauma surgery, the relationship is accidental, whereas in the military doctor and patient are on the same team. Honor and respect move equally in both directions between patient and surgeon. I know as surgeons we take care of whatever comes through the door, no questions asked, but who would we be kidding if we pretended that saving the life of a cop killer is the same as saving a GI wounded in battle? Not that anyone needed to be reminded, but the chief trauma surgeon at the hospital let it be known that nothing was to be spared in caring for a wounded soldier.
Working at Landstuhl reawakened in me a passionate connection to my patients welfare that I thought had died years ago.
Physical differences between civilian and military ORs abound. In civilian ORs hallways, counters and cabinets are stuffed with equipment, but when you need something, no one can lay a hand on it, even though you've just been promised in the time-out that everything you need is available. Conversely, the ORs in the military look positively vacated, but when you need something, its there and no one pretends to look for it if its not. There's no clutter in the military.
Civilian ORs are veritable museums of discarded high-tech toys and anachronistic instruments. To be fair, the range of cases is much greater in civilian surgery requiring a wider array of instruments and equipment, but some of the stuff that's autoclaved and laid out every day should be carbon-dated. The time-outs are done, but are hardly the main event they have become in civilian ORs.
Injuries from improvised explosive devices (IEDs) are not subtle, and there's little opportunity for wrong-side surgery, as there is doing hernias, carotids and joint replacements.
It was also my impression that the ORs were run by surgeons, anesthesiologists and nurses who worked on site instead of by administrators bunkered down at some remote location. Obviously, the composition of the work in the military is different from the civilian experience, where trauma is only a small fraction of the workload and the severity does not compare to the devastation of the blast injuries associated with IEDs and the newer EFPs (explosively formed penetrators) manufactured in Iran. Trauma surgery imposes a nonacademic atmosphere that values the practical over the speculative. There are better places than the military for creativity to flourish.
Whereas civilian ORs have become laboratories for cost containment where staples are changed weekly to save a few bucks, there is a welcome ethic in the military that no cost is to be spared in taking care of anyone injured in the line of duty. I'm going to think of this instead of earmarks and pork when I make my quarterly estimated tax payments.
We all know what war has done for surgery. Advances that benefit all mankind are a small consolation for all that war has taken away. Vascular reconstructions, wound care, hemostasis and resuscitation have been the enduring beneficiaries of warfare.
Unlike advances made by academia and industry, the military's contributions are centered on logistics. Ninety percent of deaths are still due to exsanguination, so the work is far from over, but the military continues to experiment with models that shorten the time between injury and treatment. The army is currently employing advanced surgical teams that bring fully equipped ORs to the injured, rather than vice versa.
There is no small irony in the fact that military medicine strives to preserve the very same life that warfare seeks to take away. It isn't easy to reconcile our country's obsession with saving and protecting human life with its historical willingness to wage war when deemed necessary by our leaders. I'm not going to decide that issue for you, but it was clear to me that on a one-to-one level, our military is committed to the preservation of human life. In World War II, enemy soldiers were instructed not to fire on U.S. medics because hostile combatants knew that a U.S. medic would aid any injured person. I saw this commitment to the preservation of life and the elimination of human suffering every day at Landstuhl.
A Ugandan security guard whose company was under contract to the U.S. government was brought in from Iraq after an IED blew off his left arm and leg. Protocol allowed for the man to be returned to Uganda when his condition stabilized, but the
last Ugandan sent back to his homeland in similar circumstances was found murdered within a half-mile of the airport, his prosthesis and $200 in traveling money provided at Landstuhl gone. Unwilling to allow this to happen again, the surgeons at LRMC petitioned the U.S. State Department to intervene with the Ugandan government to allow this poor man to be transferred to a U.S. hospital.
Civilian surgeons usually fall asleep when issues of disposition are discussed, but military surgeons work in a global catchment area and stay involved in disposition issues of amazing complexity to ensure as good an outcome to injury as possible.
I wondered about the psychological requirements necessary to take care of patients with the kind of mutilation all too common in the Iraq War. Advances in surgical care have improved survival even with massive injuries that leave survivors with extraordinary disfigurement and disability. Military surgery in this kind of setting is clearly a younger persons game, not only because of the incredible energy required, but also because it takes a younger, agile mind and spirit to sublimate the horrors of war into something more palatable, like the intense satisfaction of working in such a highly charged and dynamic environment. For older people like me, there was no useful distraction from the stark finality of unimaginable injuries. I knew I was only seeing one side of the story, but I felt my worldview threatened by the carnage in front of me.
I went to Landstuhl because I was led to believe that the army needed me and I was thrilled I had something to give. Instead, I got a great gift in return, one that will stay with me for the rest of my life. I got to work with men and women who, by demeanor and deed, reaffirmed my belief that we live in the greatest country on Earth. The people I met enlisted men and women and officers populate a world defined by duty, courage, honor and selfless service to their country. I find it the height of irony that political candidates bellowing for change and service to country overlook the million-plus who are already doing that and more in the military.
When I graduated from Yale more than 40 years ago, we were told we were the best and the brightest. I don't think so. We were neither. The best and the brightest had been kicked off campus, as an honest expression of antiwar activism, or so we were told. In truth, it was because the honest and purposeful culture of the military world was an embarrassment to the partisan and fragmented life on campus, where is difficult to navigate without spin and you can never really put your finger on the truth.
The military should open itself up to average citizens like me so that upon request, a citizen has the opportunity to see firsthand the remarkable culture of the military that for some reason is hidden from most of us. It was an unexpected joy indeed to finally catch up with the real best and the brightest at Landstuhl Regional Medical Center in Germany.
I had a guy sign up at CP that is a browns fan. He is a Viet Nam vet....He was a POW for three years. He is slowly telling me his story. Not sure how much will see daylight, I promised him I'd give him final okay on what gets posted and what doesn't cuz right now he is rambling.
He was kept in a tiger cage, he lost 90% of his hearing because he had his ears cleaned out with bamboo....no toenails anymore....on and on.
He said he thinks he should have died so someone else could come home.
It really is in most ways a forgotten war so maybe today we could say a prayer for people like my new friend who still can't sleep at nite.
and what is your Friends name?
Recently declassified DOD directives :
Marine Corps Rules:
1. Be courteous to everyone, friendly to no one.
2. Decide to be aggressive enough, quickly enough.
3. Have a plan.
4. Have a back-up plan, because the first one probably won't work.
5. Be polite. Be professional. But, have a plan to kill everyone you meet.
6. Do not attend a gunfight with a handgun whose caliber does not start with a '4.'
7. Anything worth shooting is worth shooting twice. Ammo is cheap. Life is expensive.
8. Move away from your attacker. Distance is your friend. (Lateral &diagonal preferred.)
9. Use cover or concealment as much as possible.
10... Flank your adversary when possible. Protect yours.
11... Always cheat; always win. The only unfair fight is the one you lose.
12... In ten years nobody will remember the details of caliber, stanc e, or tactics. They will only remember who lived.
13... If you are not shooting, you should be communicating your intention to shoot.
Navy SEAL's Rules:
1. Look very cool in sunglasses.
2. Kill every living thing within view.
3. Adjust Speedo.
4. Check hair in mirror.
US Army Rangers Rules:
1. Walk in 50 miles wearing 75 pound rucksack while starving.
2. Locate individuals requiring killing.
3. Request permission via radio from 'Higher' to perform killing.
4. Curse bitterly when mission is aborted.
5. Walk out 50 miles wearing a 75 pound rucksack while starving.
US Army Rules:
1. Curse bitterly when receiving operational order.
2. Make sure there is extra ammo and extra coffee.
3. Curse bitterly.
4. Curse bitterly.
5. Do not listen to 2nd LTs; it can get you kil led .
6. Curse bitterly.
US Air Force Rules:
1. Have a cocktail.
2. Adjust temperature on air-conditioner.
3. See what's on HBO.
4. Ask 'What is a gunfight?'
5. Request more funding from Congress with a 'killer' Power Point presentation.
6. Wine & dine ''key' Congressmen, invite DOD & defense industry executives.
7. Receive funding, set up new command and assemble assets.
8. Declare the assets 'strategic' and never deploy them operationally.
9. Hurry to make 13:45 tee-time.
10. Make sure the base is as far as possible from the conflict but close enough to have tax exemption.
( And I Love This Next One)
US Navy Rules:
1. Go to Sea.
2. Drink Coffee.
3. Deploy Marines
Go Navy !
Special Forces Rules:
1. Go in
2. Complete the mission
3. Get out
4. Tell no one
23 August 1968
his was the darkest day during the Vietnam War for Special Forces, for this was the date of the sapper attack on Forward Operating Base 4(FOB4). Quoting from John Plaster's Secret Commandos: "On that night, at Command and Control North's Da Nang compound, more Green Berets were killed and wounded than in any incident in the history of U.S. Army Special Forces."
This is an account of the incident by John "Styrker" Meyer-
NVA in the wire
These days, "Tilt" is a reporter for the NC Times.
Everyone knows that an Air Force Airman has hired at least 3 Sailors to do his dirty work! And while we are out doing our thing, we get our Cars washed and waxed! Its the American way! Plus the Air Force Chow Halls have Maître d' s and Valet parking, doesnt all the service's?
You know, Marines and Army grunts always brag about how they'll eat anything; snakes, bugs, MRE's, etc. Apparently they've never eaten food on a seagoing Naval vessel! I'll never forget when I was a young squid fresh out of my school. I was doing my first UNREP (UNderway REPlenishment), loading boxes of food onto an elevator for stowage into what I assume is a giant refrigerator somewhere below decks, and I noticed I was handling: BEEF, GRADE F on the loading pallets. I never heard of such a thing, but the small "REJECTED U.S. Penal System" stamp on the side of the box kind of bothered me.
To be honest though, the only time I've actually gotten sick from the food was when we had some undercooked chicken. Other than that, the taste is always questionable, but it makes you go and I guess that's all that matters! :icon_shrug:
I've dined like a king in AF dining facilities - Chitose AFB in Hokkaido was excellent :yes: :no:
But the squids ain't too shabby either!!
Wow, no ****, me and my boys ate at a sub base in Pensacola, and had lobster :icon_eek: :yes:
3 weeks from today and my daughter gets to come home. Hard to believe it's gonna be three months
It'll pass quickly, Darlin!1 :yes: :flag:
well I just heard from mine...............
hey dad long time no talk. well there are a few things that are new with me for one I have joined my company softball team and to be honest I am one of the best on the team everyone else kinda sucks. it makes time go by faster. I also have been recommened to go back to the soldier of the month board again. besides that things are good how are you doing, and kevin, anything new?
That's great news H8er!! :flag:
I think I'd have forgone the Grade-F beef after learning that it had actually been rejected by the federal prison system.........uke:
After boot camp he went to Germany than Iraq then germany again and now in Kansas...
From a 10 year Naval Veteran I would like to say thank you for your support to our great nation. The Family has the toughest job and for all of you out there with loved ones stationed far away, hang in there...there will be better days!!
Thank you right back, both for your kind words and your service to your nation!!!!
well, i hope you have or had a great homecoming!!
Funny when you start talking about it, how many people either shared what you feel, or served that you never even knew.............sometimes I think it would be nice to just take all the vets...list their name....branch of the service and where they served and just keep it locked. So at a glance, everyone can see. Almost like....the icon that says moderating team and that comes up. Not sure how to even do that on my own board though LOL
Thanks again LG for starting this to begin with.
Well I just heard from mine, I asked him how everything was going and if he was close to any other Mortar attacks
hey dad whats going on? anways as far as mortars no, 2nd brigade from ft campbell is out here and like a month ago they found a cashe of like 300 mortars like a mile outside the wire so there hasnt been anything lately. there was an apache attack last night in the paper this morning it said they killed like 7 insurgeons in that attack so we are preventing a lot of attacks lately.but today is the first day of ramadahn for them like their christmas and will go till mid next month and they arent supposed to kill during this period. but who knows
Good news, Bro!! :icon_toast:
Thanks for sharing that. God Bless you Both
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