Wednesday, August 25, 2004

Finding Humor ... and Dignity

Here is a portion of a letter I recently received from my doctor friend up north. In it she illustrates how it is possible to find humor even under the worst of circumstances.

"Courtesy, respect and good manners have ganged up on doctors over the past generation or so to dissuade us from referring to a patient as 'the gallbladder', 'the seizure', or 'foreign body impaction' (use imagination). We have gone to great lengths to encourage the use of formal names and titles in an effort to preserve dignity and to create an atmosphere of equal footing between doctor and patient.

The way things are organized here, the soldiers, department of defense employees, contractors, coalition forces-otherwise the good guys, are listed by their names. The Iraqi civilians and prisoners are listed by a number. Many times, we receive unconscious casualties without any information. These are the 'drive-bys' dropped off by field medics, MPs or, very often, dragged to the front gate and left there by who knows. I have discovered that a lot of the numbered patients are brown and so assumed to be Iraqi and are all considered bad guys until we get the real story. In fact, there are a lot of brown people here who actually are KBR (Kellog-Brown and Root, the US government's contractor of choice) sub-contractors and employees. But starting out brown and unconscious, the assumption is that you're a bad guy and you get a number. I guess it's like John Doe, but there are so many, we'd be numbering the JDs anyway (we are well into the four digits).

On the positive side, except for the depersonalizing number system, the human body wounds, bleeds, and heals the same, good guy or bad guy. This is fortunate because learning just one human physiology is more than enough for me and so we treat all patients the same. The only clear difference in care is in the evacuation. We can evacuate to higher level medical facilities any American or coalition civilian if they are stable enough for transport. The natives of course remain here. As it turns out, even with all our limitations, the US Combat Support Hospital System is the highest level of care in the whole country at this time.

As a result, our very critically ill Iraqis and other brown people stay with us for weeks or even months. We get to know them in a way we can't with others who are here and gone, usually within 1-3 days.

It is impossible to care for someone day after day and refer to them as #6492. We can't even go back to our old habits of naming them by their malady like 'the gallbladder' because we would have to say something like 'the multiple fragmentation injury to the abdomen with a through and through to the left chest, a comminuted femur fracture and multiple gun shot wounds to the lower extremities.' It doesn't roll off the tongue.

So, one way or another, the patients acquire names. We don't ever, that I can see, actually think about names, they just sort of take hold and spread so that the only people who really care about the number nomenclature are the admin, lab and pharmacy. Or the politicos.

I have taken pains to set this up or else I'm afraid the names I am about to tell you would seem callous. Hopefully, you can take this in some context. So here goes:

One patient had crushed arms, in splints with traction causing him to have two large, white bandage wrapped extremities held extended above his head for quite some time. Again, I don't know how or even when it happened, but he slowly became known as "Touchdown". Another man who was actually an Iraqi Interim Government Police Chief, had charged through gunfire to throw himself over an RPG (big rocket) which exploded in his belly. He did this to save a group of 6 or 7 high ranking American officials he was escorting. We ended up calling him 'The Sheriff'(again, clearly a good guy, but gets a number anyway). This stuck like glue since the only radio station we get in the ICU plays the same limited mix of 70s music everyday and so we hear 'I Shot the Sheriff' with annoying regularity. It was a natural.

A real bad guy had been shot and had his right arm vaporized below the elbow during a firefight. He was captured and was being evacuated back to the CSH for treatment. On the way, his own insurgency cell hit the evac vehicle with a booby-trapped explosive (IED). This then blew one of his legs off. He had a long recovery and came to be known as "Lucky".

Another man is called "Blue". No one seems to remember how that came about. He has been here for over 4 months and has had multple, staged, orthopedic, skin and muscle flap/graft surgeries complicted by bone infections. I can't follow the link, but he is worth mentioning because he is a true obsessive-compulsive. He spends his entire day cleaning himself with q-tips, and gauze. He looks about 70, although he is probably 50. He has a 12 inch long, snow-white, meticulously combed and trimmed white beard. I estimate he is about 5 feet tall and weighs 100 lbs not couting his external fixator devices (scaffolding for the leg). He has been placed in the part of the tent that actually has a 'window', (plastic and opague, but a window none the less) which gets diffused sunlight. His longevity, age and the fact that the nurses have turned over all wound care and dressing changes to him have earned him the prime real estate.

One thing about Blue though is disturbing. Although we have given him dental floss, he insists on pulling strings of gauze from his wet to dry leg dressings to floss his teeth. Given he is so clean otherwise, this is unusual. I am told he prefers the taste to our mint flavored waxed, packaged American floss.

There are so many more -- a guy with scars demonstrating very old, recent past, recent, and brand new fresh gunshot wounds to every part of his body. We call him Tu-Pak. One man who required massive transfusions which depleted our blood supply and so required an emergency blood drive. We drained every person with his blood type who was on duty in the hospital that day. We named him Sponge-Bob. Another guy with incredibly thick, curly black hair combed straight upward is known as Kramer. A turkish guy is "The Turk" which is not original but feels good to say.

Every name is a replacement for the anonymity of a number and a reflection of something personal about our injured people. Perhaps that is a rationalization for our behavior but I think it is on the benign end of the spectrum given the circumstances. I understand from the translators that the awake and alert ward patients have named us as well. For some reason, I am called Dr. "Mama" which they assure me is a term of respect (I'm too flattered). It's better than what they call the big Ortho guy who examines wounds, changes dressings at the bedside and adjusts traction. They call him Dr. Ala'am which means 'pain'. Mama is just fine."

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