Saturday, December 24, 2011


I really don’t know what to say anymore.  Finding the words to write into a blog about my experience here in Afghanistan has turned into an event of endless frustration and torture. Motivation has dried up in my personal drought.  Being here is a mental and emotional daily beat down. Experiencing war first hand (from a surgeons perspective) is nothing like I thought it would be and something I was ill prepared for no matter how much effort I put in prior to this deployment. Trauma has continued to flow in a bloody river of sorts. Yes, I have made a difference in soldiers’ lives but I’m at my emotional whit’s end managing war ravaged amputations of our soldier’s limbs and death.  When I’m overwhelmed with trauma my mind has a mental block to the situation I’m surviving in but when periods of monotony compose my days between the traumatic ones I find the only way to escape is sleeping. At least I can dream of my life back home; my wife, my kids and everything I love.  There is no romanticizing the job I do nor the life I’m forced to live here in Afghanistan and the same could be said for the endless ravaged heroes I care for on a daily basis, their efforts far outweigh any I could bring to this table; that’s why we call them heroes.
It seems these past few weeks have dealt the worse hand to the E.O.D. soldiers.  The volume of IED’s that insurgents are placing has increased and their wicked tactics have worsened.  Not only are the primary IED’s being placed to damage  passing coalition vehicles but secondary devices are put nearby to maim or kill E.O.D. personal whose mission is to disarm them.  One such incident our FST had to deal with is rather noteworthy.
 Four E.O.D. soldiers were on a mission to disarm a suspected IED.  Prior to getting to the suspect position they encountered an unknown large IED that blasted the MRAP they were traveling in. The force was so intense it picked up the vehicle and flipped it end to end. When the rescue crew arrived it was determined the area was unsafe due to multiple secondary IED’s in the immediate area. The extraction plan was then changed. A medevac Blackhawk was used to hoist the injured soldiers to safety and they were then transferred to our forward surgical unit for treatment. When they arrived all four were brought into our facility. Only one of the four soldiers was able to drag himself in under his own power; the others were carried in on stretchers.  It was apparent that the injuries were to the lower extremities.  One of the soldier’s legs was covered in his own blood and he was withering in pain.  It was not obvious what the injuries were to this soldier on my initial views. This soldier’s multicam uniform was quickly removed and one of our general surgeons began his trauma resuscitation while I focused on the effected extremity.  Once his pant leg was removed there was an obvious open tibia fracture staring at me. I continued to use trauma shears to cut of his leather boot and was taken back at what I saw; his foot was amputated in the middle of its length. What amazed me was his boot was completely intact with no obvious signs of trauma. The force of the blast was of such a magnitude that it caused this level of injury. I later learned the haul of the MRAP was intact so it was the shock wave that propagated through the floor that caused this injury. I immediately had our radiology technician take x-rays to further assess the damage. The injury was worse than I could have imagined. Nearly every bone in the soldiers’ foot was severely fractures into pieces no bigger than an inch or less, and the end of the tibia was unrecognizable.  This was among the worst lower extremity injuries I had ever seen.  There was no chance of reconstructing his lower extremity, thus, I was forced to take the soldier to the operating room where I amputated his leg; one of many I have been faced with here in Afghanistan.
Two days following the E.O.D. soldiers leg amputation lightning struck again; this time my emotions had a hard time controlling themselves. 
A young 19 year old U.S. female Specialist was on a mission in the rugged terrain north of Jalalabad with her fellow unit soldiers when they hit an IED. An extreme blast was encountered similar to the last group of soldiers we dealt with days earlier.  A medevac Blackhawk was dispatched to their position and they were transferred to out FST. When the Blackhawk landed they were quickly transferred to our trauma bays for evaluation. Of the four soldiers sent to us for medical care a young female specialist and an American born translator fared the worst.  My attention focused on the 19 year old Specialist. She was screaming from pain; tears drenched her face.  Her leg was covered in blood and the bottom of her boot, which was ripped open, was slowly pouring out blood. A tourniquet which was ineffectively applied to her leg was failing.  One of our general surgeons started the resuscitation while I focused on her leg. Her injury was severe to her lower leg and even though I had not seen x-rays or removed her boot I knew what was likely from the soldier I dealt with days earlier.   Our anesthesia provider was trying to calm her down with sedation with minimal success. I was able to finally remove her boot on the injured leg; everyone in the immediate vicinity was taken aback by the extent of injury. I knew without a doubt reconstruction of this soldiers leg would be unacceptable based on the severity of the injury. Amputation of this young woman’s leg was the only option.
My heart kind of dropped with this realization. This would be the first female amputation for our team and me personally from a traumatic cause.  Time stopped within myself while my mind tried to comprehend the ramifications for this soldier that are about to take place.  This soldier was young and just starting her life. She was a college student, not married and without children. Her life plans will now sail a different course that she or her family never anticipated. 
The young soldier was brought back to the operating room for her unexpected meeting with fate; and in the end mine as well.  Our anesthesia team gently put her to sleep and then my work began. Once I finished she was extubated and transferred to the post-surgical area to recover. While I was completing my surgical records the young specialist asked for me, so I went over to her side to see what she wanted.  Once by her side she looked me in the eyes and asked how everything went. My heart dropped with emotional discomfort and personal turmoil at that moment. I was taken off guard that she was not only so lucid this soon after surgery but the simple question she asked at a moment for me like this. Most times I have only good news to tell my patients; your knee replacement went wonderful, your shoulder is going to do excellent, but this soldier’s reality is different. I put my hand on her shoulder and told her what was done; her tired eye’s swelled and tears flowed and she grabbed my hand on her soldier. I immediately went into “positive mode” as I usually do in hard timed with patients. I explained the technological advancements in prosthesis design and that she will walk again. For men it’s an easier sell but for a female it’s not as there is nothing feminine about prostheses. The social ramifications seem much more negative for a female in these circumstances. I spent about 20 minutes compassionately discussing the soldiers’ situation with her and then she blindsided me with another request; can you tell my mom? Uneasily, I agreed.
When injured soldiers come to our FST and they are stable we have a dedicated cell phone for them to call their families to let them know what happened and that they are ok. Soldiers and their families are always appreciative and it gives a noticeable relief to the injured soldiers. 
The young Specialist dialed her family and after one bad connection I could hear the phone ringing in the background, then “hello” from a woman’s voice. She slowly led her mom into the situation without any specific detail of the injury. After about five minutes of patiently waiting she handed the phone to me. The soldiers’ mom really did not understand the extent of the injury and now the stressful discussion lay on my shoulders. It was as hard to tell her mother the situation as it was telling someone their family member had died back in my surgical internship.  Her mother did not take it well as would be expected; she and her husband nearby were sobbing profusely.  She had a hard time excepting the reality of the situation and must have asked me the same questions 5 times over about a 10 minute conversation. I tried to be as insightful and positive as I could. Once I was finished with the discussion I handed the phone back to her daughter. Their following conversation was laced with crying, and words of love.
My time here has been nothing short of an emotional and mental roller coaster; parts born from my Afghanistan experience and others from the stress of being separated from my wife and children.  I’ve shed more tears in the last 5 ½ months than the last 15 years of my life, some related to the injured soldiers I’ve treated but most from the heroes our FST has lost.  I was anticipating this experience would strengthen my personal fortitude but in reality it has taken my positive points of view and skewed them into jadedness.  My days have been filled with unexpected emotional forecasts and over time this lack of control becomes overwhelming. The stress of family from a distance, the constant threat of attack, soldier’s injuries and demise, and the lack of an outlet to relax deteriorates your strength as a person over months on end.  I’m not here to judge the grand reasons we are still within this theater of war. The only valid perspective I can give is my own, and can tell you on a personal level this environment is not for me.  I feel like I’ve been locked in a cage of moral negativity and pushed to live a life not of my choosing.  The army I signed up for in December of 2000 is not the army of present day. I don’t know how I will look back at this experience in 10 years and I hope I can gleam some positivity from it, but today I feel that is unlikely.  
I have a little over 3 more weeks here in Afghanistan before I start the long journey back to Kentucky. I may be leaving this war here in Afghanistan but I’ll be confronted with a different unfamiliar post war family reconstruction when I arrive home. My young boys are at war with me for being gone and don’t communicate with me at this point; although, they asked Santa for their daddy to come home from the army for Christmas. The newborn daughter I left 2 weeks after her birth does not know her father and my wife has learned to live without her husband in her daily life.  I have learned to live without the responsibilities of a father and have become a self-centered personally indulgent individual. I have a lot of social reintegration myself waiting and it’s not going to be without a sizable amount of stress. Fortunately for me I have been able to maintain communication with my family. The soldiers who are isolated living on the Afghan mountainside are not so blessed. I can’t even begin to imagine the turmoil they will face with home reintegration. 
It seems many back in the U.S. individuals support the troops in various degrees.  Some offer gratitude, nods and handshakes, and others are active in supporting our troops through their time sending care packages, writing letters, knitting hats, and making a difference in a soldiers world both in theater and back in the United States.  I don’t want to rain on someone’s proverbial parade but if you aren’t going to take an active part in making a difference in our troops lives don’t bother with the handshakes, nods and superficial forms of gratitude; we know your happy in your comfortable world where you don’t have to risk everything for a nation that we as soldiers care so much for. The last thing freedom needs is to be cheapened by superficiality. Everyone has the opportunity to make a difference. You can shy away into your protected corner or spread your wings and let freedom ring loud and clear. The choice is yours. God bless America, and all individuals who seek freedom.
Thanks for coming along for the ride.
I’ll be home very soon Melissa, Turin, Talon and baby Myla. I love you more than you will ever know.


Wednesday, November 2, 2011


Two days ago my time here in Afghanistan bled the reality my life has become.  My fellow surgeons and I were headed to the DFAC at our usual time for dinner when from out of nowhere 2 rockets passed 100 feet over our heads and landed 50 yards away in a chilling intense explosion; a deafening white and red fiery aura surrounded us. Everyone in sight scattered in disorientation. After hitting the ground on instinct we sprinted to a nearby bunker and waited for the unexpected immediate future. Within a couple minutes the bunker was filled with the stench of sweating soldiers after being filled to capacity. The familiar sounds of Apache gunships filled the distance and with it comments of mal-tidings for those responsible from soldiers in my close proximity.  A couple minutes later the sirens and audible message of “Code Delta” began.
We were not aware if any injuries were caused so after a short amount of time we sprinted back to the FST to hold our positions if medical treatment was necessary. We were held in a position of lockdown for probably an hour and fortunately no injuries were reported. We were informed the rockets hit positions just past major congregating area and left holes 4 feet in depth.  Obviously the situation could have been much worse and my subconsciousness and others were alarmed. For the remainder of the night our security was coaxed with sounds of invisible Apaches keeping watch over us from the blackness of the sky above. 
The following morning I awoke with my senses alerted unlike past days.  The previous night’s rocket attack opened insecurities within myself I have not felt before. Lately, we have been informed that intelligence sources have increasing credible information of an impending attack on our base. With the recent foiled plan of 13 internal insurgents on our base and then yesterday’s rocket attack anxiety is becoming apparent in members of our FST and surrounding soldiers. We actually were given tentative dates the attack could occur on; very soon. All we can do is prepare and hope it does not come to fruition.
Today, I saw a 5 year old Afghan girl back who many past FOB orthopedic surgeons have been involved with. Two years ago she fell into her home fire pit and sustained severe burns to her hand.  She has had multiple surgeries over the last couple of years to help regain motion and achieve separation of her fingers after they fused together following inadequate third world local treatment. This young girl has done surprisingly well and may potentially need only one more operation. Today’s appointment with me was to see how her hand was progressing. Unfortunately, one of her fingers has begun to flex further as the surrounding deformed skin has continued to contract. Through our interpreter “Max” I discussed the situation with the girls’ father.  He agreed with my surgical plan and a tentative date about a week from today was set to surgically correct her finger.  I asked Joey T to join me for the surgery as he will be pursuing a fellowship in plastic surgery in the not too distant future and skin grafting will likely be needed.  I’m excited to make a difference in this young girl’s life and so is our entire Forward Surgical Team. 
I love you Missy, Turin, Talon and baby Myla. Save some candy for daddy.


Friday, October 28, 2011

"Made in U.S.A."

It’s 4 A.M. and I’m torn from sleep by the rapid opening of the rusty steal door at the entrance of my barrack; knocking resonates from my door followed my Joe J’s voice. He informs me our special operative friends have brought us early morning business from a mission that just concluded. I force my senses to wake up, get dressed and head out the door to the FST. I open the door and am greeted by many familiar Special Forces faces that appear to be happy to see me.  Next to them is a blindfolded restrained bloodied middle aged bearded Afghan male on a gurney. My SF friends inform me this Afghan is a Taliban insurgent who was captured from the night’s mission.  They needed me to stabilize his orthopedic injuries before he is transferred to an Afghan run detention facility for interrogation and holding.  I examine the insurgent patient and identify many obvious conflict inflicted injuries and order appropriate x-rays to better evaluate them. After a review of the radiologic images I formulate a surgical plan.
It’s interesting to note this is the first confirmed insurgent I have been faced to treat. Multiple other similar surgical cases were laced in obscurity with no confirmation of insurgent intent.  But now here he is in the flesh. The enemy were fighting against that would slit our throats if given a chance; murder our wives and children. A sense of disgust boiled deep within my veins and I would be lying if I told you the non-physician part of me didn’t wish eternal harm on him. Images of the deceased U.S. soldiers I’ve treated raced through my mind compounding my distain. It took a deep internal strength to control myself and maintain a professional composure; my white coat mentality fortunately won the best of me on this occasion. Who knows, maybe the day I meet my fate and am standing face to face with my creator I’ll reflect positively. I guess the American culture embedded within my center breeds compassion as well as the familial roots that raised me.
The insurgent was prepped for surgery and taken to the operating room. His fortunes afforded him my best efforts as that’s all I know how to give in the surgical environment.  Multiple injuries were addressed and surgically stabilized. The last orthopedic procedure was his leg which required a long leg “bivalve” cast. After it was complete I felt the need to remind this insurrectionist who he should thank for reconstructing him so on his cast in big red letters I wrote “Made in USA”, maybe a passive aggressive gesture but to me and my fellow soldiers; priceless. 
The chill of a new season is descending upon us here in Afghanistan. One noticeable difference is the absence of brilliantly colored leaves of the Kentucky landscape surrounding my home. These last months in theater will no doubt be the most personally challenging for me. The holiday season is approaching at a fast pace and with it my absence to my wife and children. Daddy missed his daughters’ first Halloween costume and the exuberance of his sons as they were “Buzz Lightyear” and “T-Rex”. Pictures don’t ease the pain and time does not stop in my absence. My oldest son who is nearing 4 years old has resigned himself to near complete avoidance of me when I call home, but yet he cries for daddy when he injures himself or feels insecurity. Talon my youngest son has crying spells at pre-school during his mid-day naps that are growing more common by the day. If they only could comprehend their daddy feels their anguish. If they only knew daddy’s dreams were filled with images of them.
I love you Missy, Turin, Talon and baby Myla….

Sunday, October 23, 2011


3 weeks of my life have fallen away since my last blog. This time has been filled with a stagnant slowness that reeks when I ponder its effect on myself and my team. With the exception of a few interesting moments my world has been filled with useless boredom, infinite endlessness, and surgical obscurity.  Periods of time like this feel nothing short of prison. I’m forced to stay in this Hell physically while my mind and emotions scream to be let free. It’s almost a feeling of helplessness and loss of control; time does not stop in your absence.  Being busy is the distraction which makes this life tolerable but when that’s not available everything in life that is important to you becomes overwhelming. My lack of attention span does not do well in this environment so I have resigned myself to focus on everything and anything to bring my center to something productive; some medical but the majority not.  I find that the longer I live like this I become more secluded and introverted; something not typical of me. It’s interesting to note I am not alone. Fellow surgeons and members of our forward surgical team show similar tendencies.  The fact that antidepressant medications are so common in the military population is now understandable. Displacing fathers and mothers from their children and significant others is not natural and rarely has a positive outcome.  You lean a lot about yourself in an environment such as this.  
This past week I was asked by a member of the U.S. State Department to interview a potential Afghan orthopaedic surgeon for possible appointment in a surgical clinic just off the base. I was brought to another location on the base for the interview. Present for the meeting was the head Afghan doctor of the base, the member of the U.S. State Department, Joe J, an interpreter, and I. The scene was nothing short of a movie. Armed guards at the entrance of the room and building, brilliantly colored Afghan chairs in a circle on a handmade Afghan rug of matching intensity, and a sterling silver tea pot in the center with matching cups for all the meeting participants. The meeting lasted about an hour. I questioned the surgeon through the interpreter about his surgical experience.  The hard part was my personal comprehension that orthopedics is behind the U.S. here in Afghanistan by 30 years or so. I had to readjust my expectation of what is normal to me. If chosen this Afghan surgeon will work one-on-one with me and future FOB orthopaedic surgeons to introduce him to modern practices; something that will be invaluable to him and the Afghan population once we eventually leave this country. It’s very gratifying for me to be involved in these engagements. It’s a way for me to give to this country for their future.
One of the few traumas that our FST encountered was an IED blast to an Afghan convoy.  4 ANA soldiers were involved in the ordeal and one was critical. This is an example of protocols trumping life. In the U.S. and westernized nations when a patient comes to a hospital involved in a trauma situation a significant effort is put forth to save life and limb. After initial stabilization and operative intervention patients can be sent to long term rehabilitation and recovery units for maximum benefit. Here in Afghanistan that is unfortunately not the case. There are no resources or financial backing for these long term services so a decision has to be made on protocols which dictate the likelihood of someone surviving a traumatic situation.  The exception to this rule is American and coalition troops for which heroics are king. The worst case scenario for Afghan nationals is by far head injuries. There is no acute surgical intervention my team and I can provide for them and nowhere in the immediate setting to send them for treatment.  Imagine the detriment and emotional turmoil our team faces in this situation.  We were forced to watch a 20 year old Afghan die in front of us.  Anesthesia made him as comfortable as possible and our individual spiritual beliefs were with him. These situations don’t improve moral of our team and to a point contradict everything we learned as physicians in our training.  This game we know as life is not fair and we can only hope it improves in the long run. 
I’m at the half way point of my deployment and it couldn’t end soon enough. It’s amazing how your dreams become more vivid as the days disappear making the journey that much harder. I miss the beautiful faces of my wife and children; I miss the wind flowing over my wingsuit in the crystal blue sky. I miss more than I ever expected and my greatest motivation is knowing I will eventually make it home to everyone and everything I love.
I love you Melissa, Turin, Talon, and baby Myla.


Sunday, October 2, 2011

"Terror Plot On The FOB"

Yesterday at morning report we learned of an unknown hidden danger within the borders of our FOB.  A cell of approximately 13 insurgents somehow infiltrated the confines of our base as local Afghan national workers over the last year; two of the insurgents even made it to a fortified secure location.  An intelligence tip focused on two insurgents initially which then opened up to the larger group. The insurgents plan was a coordinated attack within our FOB for maximum casualties.  We were not informed of the specifics but know the Afghans involved were apprehended and their terror mission was debunked. 
When I first arrived to the FOB months ago I was extremely suspicious of everything and my senses were peaked. Over time they blunted as the feeling of security increases from days of monotony.  If thirteen plotting insurgents can make it on this base without notice a reevaluation of security measures is in need. My wary will restart the process of questioning everything and my fellow team has indicated they are doing the same.  Barb wire, large foreboding walls, armed guard towers and gates apparently are not enough. Internal tension and security measures have changed to a noticeable level here and I would assume the same is occurring throughout the theater.  
After an exposed terror plot and temporary loss of electrical power on the FOB my promotion ceremony eventually took off.  About ten individuals from higher command came in addition to members of both my team and Charlie Company.  Joe J introduced me to the crowd and then I gave an impromptu speech.  It was a memorable experience being promoted in theater; an event that I will carry forever. Being a member of the U.S. army is an honor in itself but when you compound this with the heroes I work with on a daily bases this honor is elevated beyond expectation.  If there was one less elevated note of yesterday it was my family could not be there with me; especially my wife Melissa who was promoted to major in the U.S. army yesterday as well.  Melissa is an emergency medicine doctor for the U.S. army at Fort Knox. My wife and I have lived parallel lives since we started medical school together.  We accepted the military scholarship and were commissioned to second lieutenants together, went to medical school together, were promoted to captain together, were together during residency training, and stationed at Fort Knox as staff physicians together. If there was ever an example of soul mates we would be the definition.  We are by far stronger together than apart and our dreams are one in the same (Disclaimer: a few minor exceptions existJ).  For the record I am the senior major as I was promoted 8 ½ hours earlier; eastern standard time is behind Afghanistan time.  Somehow that fact will not fly in our household; call it a gut feeling.  I think my wife will just consider me a major pain in the ass; domestic business as usual in the Duber household. 
Talk to you soon my friends.
P.S. Congratulations on your promotion beautiful.

Friday, September 30, 2011

"Hearts of Greatness"

Yesterday morning I was informed a Soldier would be seeing me after our morning report for injuries sustained during a mission the night before. This Soldier was different though, he was furry, cute, and showed his appreciation through licking your face and wanting to play. His name was Gizmo and he was an 80lbs Special Forces Belgian Malinois work dog.  This pup injured himself during a mission on steep rocky terrain when he slipped and fell injuring his front right side which has caused a limp ever since.  There are no orthopedic veterinarians in our region of Afghanistan so I happen to be the next best thing; after meeting Gizmo I think he agreed.  I examined him and localized his pain to his shoulder and paw.  We needed to do X-rays to further evaluate my new patient so our FOB vet gave him a mild sedative.  Once he was in a calm state we positioned him and radiographs were taken.  Fortunately for Gizmo he had no fractures and likely just contused his shoulder and paw.  His sedation was reversed and specific instructions were given to his handler which included an oral anti-inflammatory. Gizmo will follow up with our vet after 2 weeks of recovery to clear him for future missions. It’s not every day a patent of mine licks me to show their thankfulness, but as long as their cute and furry I don’t mind.
This morning I was barraged with consults and follow-ups.  It took me some time to catch up but eventually I succeeded. Sergeant W was one of the more interesting stories today.  He was sent to see me after sustaining a knee injury in a high elevation mountainous area; actually too high for a medevac helicopter to reach him. He spent more than a day at an extreme elevation waiting to see if a Blackhawk could reach him but after a period of time an airlift was not in the cards. So through rough steep terrain 2 fellow soldiers had to carry him down to a location where the altitude was amenable for a Blackhawk to reach him.  The trek took his comrades 12 hours of effortful hard earned sweat, but gallantly they succeeded and Sergeant W was medevac to our FST. I never got to meet these 2 helping Soldiers and likely will never have the chance.  They were a part of Sergeant W’s unit and he informed me that a beer back in the U.S. will not suffice; he will be buying a keg. I don’t think he will ever live this event down. Call it a hunch. After evaluating him I sent him to Germany for an MRI of his knee for further radiographic investigation.  This Soldier will likely end up back in the U.S. for surgery but his long term prognosis is excellent.
Tomorrow is going to be a memorable day for me.  I recently was promoted to Major and the ceremony will be tomorrow at 11A.M. An in theater deployment promotion is definitely a morale booster for me. I have been notified some special guests will be present for the event and feel honored. I decided the officer that will lead the ceremony will be Major Joseph Jennette one of the general surgeons on the FST with me.  Joe and I have become very good friends over the last 2 ½ months and I anticipate for the rest of our lives.  There is something about friendships that develop in theater.  It’s an intense stressful period of time in your life unlike anything the civilian world can match.  Your life is always in jeopardy, and there is not much comfort material items can offer. The only comforts are trust in the man/woman next to you going through the same experience. This trust comforts you, motivates you, and brings everything out of you. No Soldier left behind is a real mantra of life out here. I’m not on the other side of the wire like the real heroes in my opinion but I feel it.  There is a common patriotic, spiritual and emotional bond between us all and it can’t be ignored. If you’re listening or not it will eventually overcome you and instill greatness in all hearts within its grasp; it sure has mine.
I miss you Melissa, Turin, Talon and baby Myla.

Wednesday, September 28, 2011

"The Life I Left"

It’s been a long 2 ½ months since I left my family and previous life back at Fort Knox.  I left my new born daughter Myla when she was 2 weeks old and now she has past 3 month and her new smile doesn’t have daddy’s face for reciprocation. My boys Turin (4 yrs.) and Talon (2 ½ yrs.) are getting used to growing up without a father.  Phone calls and the occasional Skype is not the solution I thought it would be.  As time moves forward I see a disinterest in my children communicating with me.  Days have melted into one another and I am forced to become a single individual torn from established fatherly roots, who gets used to not being around his children; that scares the hell out of me. The social ramifications of family separation are all around me and no one is immune.  Time in this environment jades family lines within everyone in its grasp, especially soldiers with longer deployments.  When a person encounters a stressful situation they have two choices, adapt or resist the situation; most choose to adapt to lower the stress threshold.  When soldiers during deployment adapt the stress may decrease during the course of their commitment but eventually when the home environment is reencountered the adaption mechanism is called on again. This mechanism becomes a stress in its self and domestic issues can ensue; on both sides.  My wife who is an active duty U.S. army ER physician is slotted to deploy to Afghanistan soon after I return; I can’t imagine the mental, emotional, and family unit repercussions we are going to experience in the not so distant future. Kate Plus 8 isn’t a part of this movie; no Hollywood here just real life. 
The last 2 days have been relatively calm with light trauma and orthopedic consult galore.  I’ve sent 3 soldiers home for injuries that preclude them from preforming their missions; each one fighting to stay, but I have the fortune of seeing their long term when they only see today, right here and now.  It seems the volume of non-traumatic injuries is increasing as local FOB’s and aid station learn of my existence. 
Many of the trauma patients we see are under the diagnosis “traumatic brain injury” or also known as TBI.   This involves a head injury mild to severe which is usually caused by an explosion of some sort.  IED (improvised explosive devices) are the leading cause and their diagnosis is increasing.  In the past TBI injuries were poorly understood and treatments available were almost non-existent.  The high incidence of TBI’s in this war has lead the medical command as well as health care providers to better understand how to diagnosis them and also to find treatment modalities that will improve soldiers outcome.  Part of this investigation included a grant for a MRI at a major base within Afghanistan to research changes in effected individuals.  Early data from theater has found its way to the civilian side of life too. The NFL is also doing research on players with multiple concussions in a similar manner.  Together both the NFL and military will formulate diagnostic techniques and treatment plans for individuals with TBI.  We have a long path to follow but eventually our effort will be worth its weight in gold.
I miss my family J