..First, I have an alibi for the entire procedure, and you can't pin this one on me.

Second, the man was dead to me from the minute he maliciously and inaccurately accused the Marines of Haditha of being murderers on the floor of the congress in order to curry favor with the party apparatchiks.

So, in my humble opinion, his body has caught up with his sense of honor at last. It would be poetic justice if, instead of a military funeral (which, unfortunately is quite likely), he were instead buried by convicted murderers.

He apparently knows not the difference.

Good riddance to bad rubbish, and I would not be against pissing on his grave if I were ever to come across it.

Respectfully Submitted,
-doc Russia

So, just in time to overwhelm news of the boards, the next day, my wife went in to see her OB and our daughter had a few late decels, which are signs of fetal distress. Domestic-6 also started having contractions. So, weighing her gestational age versus possible adverse outcomes, the OB decided it was time to extract the kid. SO, I am very pleased to announce that I am now the proud father of a 36+ week little girl. 5 lbs. 10 oz., 18 inches. APGAR is 8 and 9 at one and five. Baby and mom are doing well. I also have to say that my daughter looks perfect. I have seen a lot of neonates in my time, and some of them are kinda ugly- like they needed more time to bake before they were ready- but my daughter really looks perfect. She has lots of hair and beautiful eyelashes and everything.

 And before I forget, let me fail to describe what I experienced when I first held her in my arms. Something happened. I cannot describe it, but it was like something reached up out of nothingness, grabbed my very existence and shook it awake. It was just a moment, but it was very strange, almost alien, like some sort of out of body thing, where it was just her and I, and nothing else. It lasted as long as an blast wave, but it was unlike anything I have ever known. And through it all, I was very calm. I was in the OR for everything, and while I knew what was going on, I felt this kind of scary calm and awareness of what was happening.  

Just got the big white envelope today.

I passed, and passed with a healthy margin. 

I was really worried about this exam, given the fact that I am not a good test taker.

So, for a reward I will be taking my wife and 36+ weeks pregnant wife out for dinner....

...and pay $1200 to take the next step in the certification process.

Respectfully Submitted,
-doc Russia

This job is starting to wear thin. I am up to my ears in paperwork and still not getting to do what I signed up for. I cannot get into details, but I took a lower paying job in order that I might be able to both screw Obama out of my tax dollars, *and* get to do specific activities that I enjoyed as part of my job. Well, the pay is still low, but I am not doing what I signed on for. I cannot count the number of times where some meeting was supposed to take place to advance this objective, but either it didn't happen, or nothing came of it. Right now, all that is going on is more meetings. It is the definition of all talk and no action.

sigh.

I also have been scheduled for night shifts 80% of the time, which means that when these meetings take place, it is the equivalent fo being in the middle of the night for me.It's like working a nine to five job, but then having to come into the office at 2am for a meeting which generates nothing. 

I haven't gone to the range in weeks, either.

Time to start looking for a new job, I think.

I don't mind working hard, but if my employer is not following up on their end of the bargain, then I should take my talents elsewhere.

Respectfully submitted,
-doc Russia

I hate the peripheral administrative tasks I have to do with my job. I really do.

Not much going on with me right now. Had a scare with the missus over the weekend, but she and baby are still chugging along.

I am spending my time getting ready for the baby, so I am kind of consumed right now.

If you don't hear from me for a while;

MERRY CHRISTMAS!!!

R/S

-doc

... Changing the standard military round to the 6.5 Grendel, I present to you exhibit A .

Holy smokes, that is an awesome cartridge. By the time it gets downrange, it also has more kinetic energy than a .308 would at the same range.

Respectfully Submitted,
-doc Russia

So, to sum up, it appears that there will be 30K troops deployed soon and staying until 2011. This will be done so that he can draw them down before elections. Besides the obvious injection of politics into military strategy (which can *only* have  deleterious effects), there is something else I want o point out. Okay, a couple of things. First, presumably, after so many months of dithering deliberating, This must succeed. After all, Obama had lots of time to think about how to make it work. It was he and his advisors who have said that this is an important decision, and have on multiple occasions pointed out the gravity of the decision. Having applied due diligence and deliberation, Obama cannot argue that he made a hasty decision. No, this was very well thought out by his own admission. If it fails, it's not because of anything other than the fact that he failed. He cannot claim that his intelligence was flawed, or that there was something else going on to cloud the picture. He had plenty of time to gather whatever facts he needed for his decision.

But the second point is the more important, and the more concerning. His strategy is to add an additional 30K troops for 18 months. Had he made this decision 6 months ago, instead of dithering deliberating on it, that troop level could have been established  6 months quicker. This would have increased the likelihood of success. In fact, because Afghanistan gets shut down during the winter, you have a scenario where 6 months in the summer is equivalent to a almost a whole year of operations. What's more is that because this surge will only cover a single summer due to timing, it will effectively be only a single fighting season in Afghanistan. 

The result is that his dithering has halved the effective time that the troops have to accomplish their mission.

It is quite apparent to me that Obama has made a political decision, not a military one. It pains me to know that US Marines are going to die needlessly (as they already have) form his political machinations.

I was also wrong about something. I had, years ago been of the opinion that the left was so enraptured with the Democratic party that they would rather this country fail under a democrat than succeed under a republican. Judging by their continued insistence on failure at any cost, and their disappointment at the Obama's faulty and anemic strategy as minimal an effort as it is, I can only conclude that I was wrong; they just want America to fail, and they don't give a damn on whose watch it is.

Respectfully Submitted,
-doc Russia

So, to sum up, it appears that there will be 30K troops deployed soon and staying until 2011. This will be done so that he can draw them down before elections. Besides the obvious injection of politics into military strategy (which can *only* have  deleterious effects), there is something else I want o point out. Okay, a couple of things. First, presumably, after so many months of dithering deliberating, This must succeed. After all, Obama had lots of time to think about how to make it work. It was he and his advisors who have said that this is an important decision, and have on multiple occasions pointed out the gravity of the decision. Having applied due diligence and deliberation, Obama cannot argue that he made a hasty decision. No, this was very well thought out by his own admission. If it fails, it's not because of anything other than the fact that he failed. He cannot claim that his intelligence was flawed, or that there was something else going on to cloud the picture. He had plenty of time to gather whatever facts he needed for his decision.

But the second point is the more important, and the more concerning. His strategy is to add an additional 30K troops for 18 months. Had he made this decision 6 months ago, instead of dithering deliberating on it, that troop level could have been established  6 months quicker. This would have increased the likelihood of success. In fact, because Afghanistan gets shut down during the winter, you have a scenario where 6 months in the summer is equivalent to a almost a whole year of operations. What's more is that because this surge will only cover a single summer due to timing, it will effectively be only a single fighting season in Afghanistan. 

The result is that his dithering has halved the effective time that the troops have to accomplish their mission.

It is quite apparent to me that Obama has made a political decision, not a military one. It pains me to know that US Marines are going to die needlessly (as they already have) form his political machinations.

I was also wrong about something. I had, years ago been of the opinion that the left was so enraptured with the Democratic party that they would rather this country fail under a democrat than succeed under a republican. Judging by their continued insistence on failure at any cost, and their disappointment at the Obama's faulty and anemic strategy as minimal an effort as it is, I can only conclude that I was wrong; they just want America to fail, and they don't give a damn on whose watch it is.

Respectfully Submitted,
-doc Russia

Having had some time to calm down and focus on other things, I went back to revisit my thoughts immediately after the Ft. Hood shooting. Mr. William B O'blivion worte some lengthy, and accurate comments pointing out where I had flawed logic. To sum up, it would not be right to go after Hasan's family. Actually, While technically I just was using that as an example of how badly I wanted to make him feel some pain, I should not have even used it as an example. To the bigger question of how to behave towards muslims, it is still a sticky question. Yes, there are certainly some muslims who are worthy of being called human beings, and a rare number who are worthy of being called honorable men, the fact is that the religion as a whole has become dominated and defined by this jihaddist bullshit. I wish that it were different, but it is not. This is why the counter argument of pointning out historical christian or jewish  indiscretions is flawed. Since it's inception, the christian and the jewish traditions have a historical record of reviewing their scripture and finding it's contemporary application. This is why mass in no longer said in latin. Vatican II came around, and said that a gew things were outmoded and not necessary for observation in the modern world. Saying mass in Latin was too exclusionary, so the practice was changed. A few hundred years ago, it was appropriate that mass was in Latin so that no matter what the native tongue was, the scripture and the mass was always the same. Modern translational abilities and a centralized authority in the Vatican allows for such evolution.

Islam has no such animal. As far as I know, what was written in the eights century is still being applied directly. There is no philosophical discourse in Islam. Islam never had a Nicene council, or a second Vatican council. for the thousand years that it has been taught, there has never been a time when the Muslim big wigs got together and explained what way it was that the quran should be interpereted in the modern world. For this reason, the genocide of tribal warfare is still the modality within which Muslims operate. Entirely appropriate for the eighth century. Of course, in the eighth century it was more acceptable to wipe out an entire civilization in order to protect your own. For instance, there is a reason that the tangut culture is not widely known of. The tangut ran afoul of Genghis Khan. Now they are a historical footnote.

But I digress. 

This Jihadi stuff has to be stopped. I mean, either it will be stopped, or it will detroy us, and I for one, have no desire to go the way of the Tangut. So, this begs the question of what to do with Muslims, especially muslims serving under arms. It has occured to me that perhaps we should tear a page out of our grandfather's playbook.

During WWII, Japanese Americans Americans of Japanese descent fought in WWII, as a seperate, composite unit. I am beginning to think that this may be the way to go with Muslims, as well. In this way, they can write a new chapter, and they can have their own honor. It would not only protect other soldiers from such attacks in the future, but they would be both performing an invaluable service for their nation (after all, the political value of being avble to deploy an openly and definitively muslim unit to a muslim country for counter-terror operations cannot be underestimated)as well as fighting to redeem the honor of muslims as well as blaze a trail for others to follow. 

Now, to be sure, it would be a unit that would be sent on some of the most dangerous missions there are. It could be no other way. If they were relegated to some sort of dog and pony show circuit for public affairs officers, then it would totally destroy the purpose of having such a unit. No, they would have to go in harm's way. They would have to fight twice as long and twice as hard. They would have to, lest they be regarded with disdain as a unit of non-hackers. They would have to risk and suffer more in order that there is no question that they have earned their place along other warriors.

Maj. Hasan would have been sent to such a unit, and he would have been corrected or kicked out. 

anyway, I cannot paint everey muslim with the same brush as Maj Hasan anymore than I can paint every soldier with the brush of Abu Ghraib. I cannot. That said, there are plenty of examples of virtuous soldiers. In fact, it is the norm.

What is normal for Muslims to believe is less clear, and therefore, more circumspect.

Make an all Muslim unit in the Army. Give them their chance to prove to their countrymen that they are worth a damn.

Respectfully Submitted,
-doc Russia

So, the reason I am quiet right now is that I am eyeball deep in studying for my boards. I am a horrible test taker, so I need to do everything I can, and maybe...*maybe* I'll pass.

No bloggin'

R/S,
-doc

It turns out that Napolitano is trying to "deflect a wave of anti-muslim backlash" following the Ft. Hood shootings.

Well, maybe she should have tried addressing the muslim threat instead of sending out memos about the threat of returning veterans .

R/S doc

I had actually started this as a comment at Grim's Hall, but I should put this up on my own site.

Seething rage does not illustrate my feelings right now.

I want to go after his family. Now that I know that he is alive, I want him to receive weekly care packages of pieces of his relatives that have not decayed, (and are still fresh so that he knows that they are still alive and suffering) for the next twenty years. I want this so that he will know the pain that his loved ones are suffering. I want to hurt them in order that I might hurt him. I want him to know anguish, and I want it to last him for the rest of a long, long life. I want him to beg for death and be denied. I want to drive him mad with grief. Then, after he has grown too old for pain, I want his carcass to be fed to pigs so that all that is left of him on this planet is pig shit.

None of this shall come to pass, but I want it to.

Never trust a Muslim.

I can no longer consider them to be human beings after this. If a muslim is killed, I will bear no witness against his murderer, and I will acquit his murderer if charged. This is the rules that they live by, and this is the rule that I shall give them.

Yes, there are some muslims who I like, but as much as I enjoy their company, I would gladly give it up for all eternity as long as this is never able to happen again.

Maybe I will feel differently about this later, but right now, this is where I stand.

Respectfully Submitted,
-doc russia

So, this Halloween was a lot different from the ones that D-6 and I went through in previous years. We had, over many years gotten into the habit of only buying a nominal amount of candy for Halloween, and then having no trick-or-treaters. We lived in not so nice neighborhoods, so people did not trick-or-treat. This year was *completely* different. There were lots of kids in this neighborhood, and they *all* came by. In fact, judging by the appearance of kids who didn't speak english, I am fairly certain that parents drove their kids to our neighborhood instead of trick-or-treating in their own. It was very nice to see all these young kids dressed up as who-knows-what greedily grabbing for sweets. There was this one kid who was about 5 years old, who I thought his hands were so small, he wouldn't be able to grab a golfball single-handed. Well, his hand went into the basket, and came out with a tether ball sized fist of candy. I was shocked. There were also a cute set of twin girls who had huge costume ears, and I couldn't recognize what they were. The Harry Potters, Luke skywalkers, Princesses, goblins, and all were easy, but I had to ask the girls what they were.

"Blood elves"

In stereo.

I did not ask for explanation. I just opened the basket, and let them pilfer away. Whatever blood elves are, they do not sound very pleasant, and inappropriate for cute little girls. Still, at least theyweren't dressed like hookers or Brittney spears (though I repeat myself), soI just will let it go.

Anyway, I have to get back to work!

Respectfully Submitted,
-doc Russia

Yes, I have been quiet as of late. I have been doing another tac med course. This one took more hours each day, and had more PT going on. I am getting to the point that I think that the best program would be one which had a certain amount of classroom instruction, but would rely largely upon scenario and force on force training for driving the lessons home. I think that PT is of marginal usefulness in a two week course, and of even less worth in a one week course. I think it is far better to understand the physical demands of being an operator by doing scenarios which require physical fitness. Running around in formation does not teach the importance of PT nearly as well as dragging an injured patient (mannequin) out of a dark corner corner by crawling on your belly with a gas mask on.

Just my thoughts.

Anyway, I have to go to work, so I am going to go get ready for another shift.

Respectfully Submitted,
-doc Russia

So, last night's shift was pretty benign. Workups and dispositions on patients were pretty straightforward. No real diagnostic dillemmas. Just kind of moving meat, and actually having a lot of fun doing it. These off-service interns scare me every now and again. they do funny things like neglecting to mention that the patient they think is a nothingburger is tachycardic. Or that there is an afferent pupillary defect. Or, that there is snuffbox tenderness. Still, no big deal. I mean, they are 'terns, and that is what they do. I don't berate them or scream and yell; there is simply no need. Missing an important finding and being notified about it is usually enough of a bad feeling in these adults. They get the deer in headlights look, and then I explain to them why that little nugget of information was important to drill down on. Had a good crew, nurses included. Things went smoothly.

Until the last 30 minutes.

30 minutes before the end of the shift, a young patient rolls in who had been involved in a house fire. I go over with the resident (2nd year), and find myself nervously hovering over her like a helicopter parent while she does the intial exam. I am nervous because we may have a rapidly closing window of intubation, and I am anxious to know her findings. She calls the airway clean, but I know by watching her that she didn't get a good look. I grab a tongue blade and check myself. Sure enough, there is carbonaceous sputum (Spit made black from soot) in the back of the throat. I call her back and show it to her. I then ask her what this means, and she stammers a bit,unsure. "Do you think this might warrant intubation?" I ask her. She guesses so. "Your G-Damned right, it does."

I call for the RSi kit, and ask her what other orders would be indicated at this time. She rattles off the CBC, BMP, ABG. I tell her to also *always* get a carboxyhemoglobin in possible smoke injuries. Done. The burns fellow shows up and we start chit-chatting. He does not recommend intubation at this time. The guy has no burns, or indications of burns- he's a straight smoke inhalation injury. poorer outcome if we intubate him unnecessarily, he says. The patient starts coughing, and has another "spell." I figure out later that they are seizures. The birns fellow is now unsure. Recommends observing the patient and intubating as needed later. He's hoping it won't be.

Hope is not a strategy.

I order the intern to tube him. He's crying and scared. I do my best to reassure him. I don't tell him the bad stuff; he's altered and acting goofy. I need him calm. I quiz the resident while this is going on about what meds she wants to use for the RSI (rapid sequence intubation). Smart girl, gets it right, and opts for the rocuronium. Low probability that this patient has a high potassium, but the risk is there, and liberating more by using sux will anger the gods and put the patient in a likely lethal cardiac arrest. The drugs are pushed, and the patient stops crying. He relaxes. I'm holding cricoid pressure as the meds reach full efficacy. The resident takes a look. She's having trouble, but I let her continue while the patient lies still, unable to breathe. After longer than I like, she asks for the tube. I feel it go in. Took her a while, but she was successful. It was probably a surprise to her to try to hit vocal cords that are soot-stained amongst blackened tissue. tough, but she did it, and grew that little bit stronger as a physician by the challenge. 

More informatin from the paramedics. Fire started in the bathroom. Lots of plastics.

I ask the resident (who by now must feel like I am riding her ass just to be mean) what we should be considering in a patient removed from a fire who suddenly loses consciousness. 

Blank look.

I add on that there was a lot of plastic burned.

Blank look + shaking head.

I ponder for an instant if I am being too hard, or expecting too much, because I kind of thought she should get this one.

"Cyanide" I say.

The light goes on, and I have her fetch the antidote kit.

I never actually used one of these before. Hell, I don't think that I have ever seen one of these before.

Still, the mnemonic I made up in med school to remember the order that the amyl nitrate, sodium thiosulfate and sodium nitrate should be given in somehow leapt back to my forebrain.

It was shift change, and suddenly the nurses disappeared.

I started drawing up syringes from ampules, and went to work. Bypass the first medication due to formulation constraints. Give the second one slow, and the third one fast right behind it.

I told the resident to page toxicology and also ordered some additional labs that I thought would be useful. Tox came back with recommendations, but I had guessed right, and they were already done, labs and all.

By now, the patient is tubed, lined, loaded, sedated and restrained. He still looks dusky. I wonder what the Hell will happen to him and grab a sticker to find out later.

My boss shows up, he had been watching. He asks the nurse a few questions. gives me a thumbs up, and leaves.

I, in turn, talk to the resident. Now that the stress of the moment is over, and the patient is stabilized, she is energized by the case.

I'm tired.

It was her first patient of the shift, and my last.

I try to make a few points and pearls, but mostly I am spent.

I write a nice note trying to capture the essence of what I did and why I did it. Can't write "decided to go big or go home" so I wrap it up in that nice, sterile and intentionally understated medicalese which makes it seem like the decisions were clear cut, and based on solid information, when the truth is that they were largerly judgement calls based upon spotty and/or inaccurate information.

I sign out and then I punch out. 

Less than an hour later my pregnant wife is barefoot in the kitchen making me some eggs as I tell her about the case.

And then I sleep. I sleep like I earned it.

Respectfully Submitted,
-doc Russia