Rolling Thunder

The MRAP is an awesome vehicle for getting around the battlespace. It can protect you from almost anything the enemy can use against you. But it is first and foremost a weapon. Like any weapon or inantimate object, it makes no distinction who or what incurs its wrath. Most MRAPs are very heavy, weighing between 12 and 20 tons. When the the driver looses control it can be a disaster.

The MRAP pictured above had a rollover about 2 weeks ago. From secondhand reports the vehicle was going fast and the dust from the road obscured visiblity. The vehicle hit an uneven spot and rolled completely over(They are top heavy). Thankfully and only due to Divine intervention, there were no serious injuries. The passengers dutifully strapped themselves in as instructed. Luckily the gunner was thrown clear since the crushed turret as seen above would not have been a healthy place to be situated.

Having made about 50 trips in MRAPs so far I can tell you that it is easy to become comfortable and even complacent in your operation, preparations and drills. The Commander of our base mandated that everyone on Spann take a look at this MRAP. The visual representation of 20 tons of Rolling Thunder will certainly make me more attentive to my part in the safe use and operation of this type of vehicle.

Thanksgiving Day and Eid

It was a nice slow low key day here at Camp Spann. The almost continuous winter clouds did not open up and rain today. I did a tiny bit of work today(for those who are going to deploy, pay attention to when your Information Assurance certificate runs out, it took me three hours with our slow connection here to finish it, and had to print it off today.)

Thanksgiving Day has been celebrated usually on the 4th Thursday in November since the time of Abraham Lincoln. In retrospect we have much more to be thankful for these days then they had in 1863. While our country is not at peace, we are not at war among ourselves. In fact we are trying to assist a country under the assault of terrorists. We think of it as a family time. I am sure that many a soldier was away from his family in 1863 though. We are a nation that is truly blessed, and while we should thank God every day, it is fitting that we set aside a special day as a nation to thank Him.

First there was the food at the Chow Hall. Like many facilities here on camp, it is run by the contractor Kellog Brown and Root(KBR). While KBR and other companies like Hallyburton have had their reputations besmirched during the last 8 years of conflict, I must say they put on a nice Thanksgiving Day meal. Pictured is my Supper tray, which was very similar to my Lunch tray(I basically came back for seconds in a few hours). The turkey was good and juicy, The stuffing was very good and I got to drench it with lots of gravy. I had mashed potatoes and shrimp cocktail. I have taken a liking to collard greens since our chow hall caters to the leading unit here, which is from Georgia. I had Welch's sparkling grape juice(known as King and Queen juice to my kids) for lunch and the more traditional mixture of Sprite/7up and cranberry juice for Supper. It was funny watching some of our European allies. Their eyes lit up as they saw the bottles on the table, only to turn to a frown as they realized it was not wine. There was pumpkin pie, ice cream and cake available for dessert.

The Church Service was after supper. We had about 2 dozen faithful attend. Represented were all three US services deployed here, US contractors and allies from Norway, Croatia and Sweden.

There was even a very nice piece of special music from an irregular quartet of US, Croatian and Norway mixture. The singing and fellowship was good. It felt altogether right to attend a service on Thanksgiving Day.

Finally we come to Eid. The Afghans have started a Holiday as well; Eid e Qurban قربان‎ عيد

This is known as the Eid of Sacrifice. It commemorates Abraham's offer of sacrifice of his son Ishmael from his second wife Hagar according to Muslim beliefs. It starts with the end of the Hajj حج‎to Mecca(tomorrow). Most Afghan businesses and nonessential government work has stopped. It lasts about 4 days, so I really don't plan on hearing from my counterparts or interpreter until monday or tuesday. That's alright since I will need to spend a little more time in the gym to work off the excesses of today.

I am also most Thankful for those of you at home who support me here, or have had to double up and do the duties and tasks I would do if I were there.

COMISAF on Board

It was a cool damp day on Camp Shaheen. Camp Shaheen is the Afghan National Army camp of which Camp Spann is only a small part. Usually I spend nearly all my time on Camp Spann, but not today. Today I was to standby in case a brief was needed about my mission here. In the early morning there was snow on the mountains in the distance. I really wished that I had brought my gloves or put on some long underwear.

I saw the German helicopters come in low and fast. It was a few minutes until the buses arrived. The Afghan honor guard came to attention and was inspected. He spent quite a while talking with the Afghan Corps commander and his staff. Then he was led to the HEAT trainer. This is exactly the same set up I had to go through in Ft Riley, where you practice rollover drills in an armored HMMWV. The Afghan soldiers who were going through it were laughing as much as I was when I did it. Then I actually got a look at him as he discussed issues with local Afghan Army basic training commander. Shortly after this I had the honor of shaking the hand of General McChrystal as he boarded the bus back to the heli pad.

From my observations I can confirm the descriptions of him we see in the press. He was humble and respectful. Over 90% of his time was spent talking with Afghans, as is only correct in a counter insurgency(COIN) situation. He listened much more than he talked, but when he did ask a question it was always pertinent, succinct and to the heart of the matter. He had a ease about him and was quick to smile.

Also touring with him was the Deputy Commander for Nato Training Mission- Afghanistan, Major General Ward, of the Canadian Defence Forces. Our little two man team falls under his command. He cheerily introduced himself while sitting on the bus with me. He asked where I was from and what my mission is here in Afghanistan. I talked with him about the ANP medical system and what we are doing to assist infrastructure and first responder casualty training for the ANP. He listened and was very kind in shaking my hand has he headed off to the helicopters as well. It is not an every day occurrence to have the Commander of ISAF and several other Generals all on board Shaheen at the same time.

khaagbad, bo-ron and gel

Today was a hectic day.

We spent the first half of the day meeting with our Afghan counterparts. There are about a dozen issues in which we are moving forward. I am proud that we have worked together to come up with a syllabus and book to teach a Trauma Assistance Program(TAP) to Policemen in the Northern Region. That gets us one step closer to actually starting the course and handing it over to our Afghan friends to run on their own. TAP is a police version of the Combat LifeSaver (CLS) course which has been so popular and necessary in the US Armed Forces. It is only right that the Afghan National Police, who are taking casualties at much higher rates than the Afghan National Army, or Coalition Forces, should have this information.
We are also very close to turning over a new clinic. It is almost completed and will have many amenities that his current clinic lacks. Reliable electricity, running water, and ground floor access are the top ones that come to mind. With this new facility will come new capabilities and responsibilities.

The second half of the day was spent travelling. This is where we get our Dari words for the day. I travelled to the site of the new clinic with some engineers inspecting the facilities. I was hopeful that I could be there to supervise the turnover of keys to my counterpart. The trip was initially a slow one. A dust storm or khaagbad had moved in. It was not like the movie sandstorms where torrential winds blast huge chunks of sand at high velocity. It was some wind and lots of dust in the air. It looked like someone had burst open many sacks of buckwheat flour into the air. The lighting almost looked like it does at twilight or during an eclipse. I was hesitant to talk too much outside, since every time I opened my mouth I was rewarded with the satisfying crunch of sand on my teeth afterwards. The floor of the clinic was still wet after painting and sealant, so it will be turned over in a few days. I will probably not be able to be present during the transfer, but will be able to coordinate the process by phone.

During the trip back the storm changed from khaagbad to bo-ron. Bo-ron is rain. While I have mentioned rain a few times, this is the first real rain I have witnessed in Mazar-e-Sharif. It was not a tropical deluge, but I was soaked after walking about 200 yards. The bo-ron leads us to our final word of the day, gel. No, I am not talking about a hair care product mostly seen in the hair of our German colleages. I am talking about mud. Bo-ron + dirt=gel. Thankfully we recently got a new shipment of gravel around the camp so it is not too muddy. Now I will have a chance to clean myself and my gear after a day in the elements.

A Tribute to the ALO

Almost every time I leave Camp Spann, it is after coordinating with the ALO. ALO stands for Air Liaison Officer; The officer who books flights and schedules the convoys to and from the airport to connect with those flights. It is a fairly thankless job, which our ALO has done very well. I know that as our plans have changed, as they have done very frequently, he has always worked to support us in a thoroughly professional manner. He is a superb example of an officer working way outside his usual field while deployed and doing it very well. He went through the same training class that I did at FT Riley. In fact he was only one bunk over in our 40 man bay. He has let me sit up front during several of the convoys in MRAPs. Finally, however, he is leaving in just a few weeks. It will be quite a loss for the mobility of Camp Spann when he departs.

As is only healthy, our ALO has a good sense of humor. He has the below creed posted on the wall of his office. It may have some terms that are unfamiliar, but if you have every watched the movie A Few Good Men, you will recognize the speech the COL makes while at the witness stand. Thus, courtesy of the ALO, I give you A Few Good ALOs

Son, we live in a world that has flights and those flights need to be booked by men with emails. Who's gonna do it? You? You, Battle Captain?
I have a greater responsibility than you can possibly fathom. You weep for ISAF flights and curse the ALO; you have that luxury. You have the luxury of not knowing what I know: that your early convoy show time today, while tragic, probably saved lives and that my existence, while grotesque and incomprehensible to you, saves lives.
You don't want the truth because deep down in places you don't talk about at parties you want me booking your flights, you need me booking your flights. We use words like CONOP, Showtime and SP. We use them as the backbone of a life trying to move people around. You use them as a punchline. I have neither the time nor the inclination to explain myself to a man who rises and sleeps under the freedom of movement I provide and then questions the manner in which I provide it. I would rather you just said "thank you," and went on your way. Otherwise, I suggest that you hop in a MRAP and drive a convoy. Either way, I don't give a damn what you think you are entitled to.

The Bug Bite that keeps giving

This photo is of a patient who came up to me about a bug bite problem. He didn't recall any bite, but the red spot had been present for about two months. He had casually inquired at the base clinic early in the process and was told to use some steroid cream on the spot, it should go away. He had done some research on the spot himself by the time he had come up to ask my opinion. I took one look and knew that a lesion like this; non-healing, ulcerated, red with a fresh looking scar was leishmaniasis. This photo was taken the day he went for specialty treatment for this problem.

Here in Afghanistan, the bite of the sand fly can carry any of several species of protozoa of the family Leishmania that can cause disease. It occurs in South America, Central America, the Mediterranean Sea, Subsaharan Africa, Southwest Asia(including Afghanistan) and India. There are three categories of Leishmaniasis: Visceral, Mucocutaneous, and Cutaneous.
1. Visceral Leishmaniasis also known as Kala-azar, is more common in Subsaharan Africa, but can also be found in most areas of Europe bordering the Mediterranean Sea. Since Visceral Leishmaniasis occurs in areas with limited healthcare access the disease can result in fevers, ascites, and is fatal within 2 years if untreated.
2. Mucocutaneous Leishmaniasis affects primarily the mucus membranes of the nose, mouth and throat. These areas scar and can essentially collapse the face, resulting in severe socially limiting deformity.
3. Cutaneous Leishmaniasis is the 'best' type to get. Progression to one of the other categories of Leishmaniasis is possible but unlikely. My patient has cutaneous leishmaniasis. It generally persists for several months before diagnosis. In some cases it will resolve spontaneously leaving a large and unsightly scar in the area. In other cases, like above, treatment can help resolve the lesion faster. Even after effective treatment that heals the wound, reactivation of the disease can occur in some patients.

There are a variety of confirmatory tests for Leishmaniasis: Fluid aspirate cultures, tissue cultures and exams, enzyme tests. None of these are 100% accurate.

Cutaneous Leishmaniasis is very common in Afghanistan. So common that I heard parents in more remote areas will scratch some infected tissue into a cut on the leg of children so that they hopefuly won't get the lesion on their face. Cutaneous Leishmaniasis can result in the protozoa being transferred to other open wound areas - effectively spreading it to other parts of the body.

While different categories of Leishmaniasis are treated differently, it is curious how the USA differs greatly in treatment from the rest of the world. The most effective treatment for cutaneous disease are pentavalent antimony antibiotics. These effective but side effect riddled medications have been used since the 1940's, although resistance is on the increase. For cutaneous disease most other countries in the world, including Germany, use local injections of pentavalent antimony into the lesion daily for approximately 30 days. For US forces, this is not an option. A US servicemember who has cutaneous leishmaniasis must return to Walter Reed for 30 days of IV treatment with the pentavalent antimony drug (PENTOSTAM). The side effects of this drug are significant and potentially life threatening, so patients are hospitalized for the length of their treatment. Side effects can include the usual suspects of joint pains, GI upset and fatigue. The more concerning issues are electrocardiac abnormalities, anemia, elevated liver enzyme levels and low white blood cell counts. I am not sure why the CDC and Army chose this approach. It does have a good cure rate at 94%, but the potential for causing more harm that good is not subtle. Our German colleagues think we have lost our medical minds when we discuss the differences in treatment. Some antifungal drugs can also be used to treat cutaneous disease as well.

I wish I could say the gent who's leg is pictured is the first case I have seen among US forces here. I cannot. I have seen at least 5 cases in the few months. There are also many more cases among our Coalition partners here. I have only heard of one fatality due to visceral progression of a Coalition soldier a few years ago.

So while we think about the dangers of bombs and small arms fire, please also consider that US forces overseas are at risk for a variety of diseases we usually do not encounter at home. Disease and Non Battle Injuries (DNBI) are usually the highest percentage reason that military forces are not mission capable. Overall I think Coalition forces have done well to mitigate the many risks to our health here in Afghanistan.

The good news? Prevention is the best medicine. Wearing long pants and even shirts during dusk to dawn can prevent getting a bite. Also use of insect repellant. The simplest things are often the most effective, yet without constant vigilance, the most elusive.