All in a day's work

As you look at these photos, I’m sure you wonder what an Air Force nurse practitioner is doing flying around Afghanistan in a Blackhawk helicopter. This is one of the best, yet little known, benefits of my current position. In addition to providing medical support to our driving missions throughout the province, we occasionally put together air-assault missions. When we do, one of us medics generally goes along, “just in case.” Our soldiers are well trained in combat lifesaver skills (see prior post) but when things go wrong, the first thing they usually yell is “Medic!” and they like to know we are there to help.

Our mission last Thursday was to the western region of a province we are in the process of handing off to a new PRT (Provincial Reconstruction Team). To do the handoff appropriately, we needed to perform quality assurance checks on these projects, but driving would take several days, and there was no guarantee we could reach all the destinations. Because of safety concerns, we have started using only MRAP (Mine Resistant Ambush Protected) trucks and there is some belief that they are too large to navigate the terrain.

I have to admit flying is much better than driving. In addition to the adrenalin rush, we were able to see the three projects in just a few hours. As the mission medic, I carried enough supplies to treat the soldiers, if needed, including intubation equipment and pain medications. I also went fully armed and was responsible for additional security at each objective (not your typical day as an NP!).

Thankfully, the mission ended up being routine and, other than a couple hard landings, we had no incidents. I managed to jump in and out of the helicopter every time, without seriously hurting myself. I did wound my pride—and bruised my ribs—when I jumped out of the Helo, threw myself forward a few steps and landed in a “defensive fighting position.” Apparently, I was supposed to land on my knees, elbows and the butt stock of my rifle rather than my abdomen/chest. Oh, well, lesson learned!

I have a few days to recover while the rest of the team conducts a series of missions. Then, it will be back to work for a few days prior to the start of my leave (two weeks alone with my spouse in Germany!!!). More to come as the adventures continue.

Lori

A man's world

Have I written yet that I am living in a man's world? Some days I don't notice and, on other days, it smacks me right across the face. Those of you who have spent any time in or around the Army are rolling your eyes. Of course, it's a man's world and we women are outnumbered. The Army still has career fields that are exclusively male and all of our security force here on the PRT [Provincial Reconstruction Team] are members of one such career field. I guess it just still catches me off guard, since the U.S. Air Force and the medical field, specifically, seem to have a better balance of men and women.

Here on our team, fewer than 10 percent of the organization are women, and I am the only female officer. We ladies stick together; none of us are too “girly” and we manage to fill the “little sister” role pretty well. We climb in and out of our big trucks without help, lug our 30 pounds-plus medic bags around and clean our own weapons. I even helped unload ammo from the trucks the other night after a long mission. These things do not bother any of us and they actually make us feel like valued members of the team. We can carry our own weight and pull duties with the men, thank you very much!

So how does it hit me in the face? There are portable toilets here where the seats are on a spring to stay in the “up” position.They're still easier to deal with than the ones that are just a hole to stand over. I won't even get started on that. Then, I was told the other day that there is a “discussion going around” that I shouldn't engage in talks or carry out what we call key leader engagements with senior Afghan leaders in our province, most of whom are men. Why? Because I am a woman and they don't respect women like westerners do. My response? “Reeeally? Huh. Well, let's go see the governor!” So we went to see him and the meeting was fine. Now, mind you, I will never meet alone with any male Afghan officials; my security and interpreters would never let that happen. They are pretty protective, which, to be honest, is where the being-a-woman-in-a-man's world thing is sometimes nice.

With the pending elections, it will be interesting to see what changes happen in our province. For example, here the governor is appointed by the president, not elected by the people. There are representatives in the province who are elected, and this is part of the pending process, as well. Two of these positions are held by women and they are true heroes; they must walk a very fine line between being a respectable Afghan women and promoting themselves as serving the people. I look forward to meeting them soon and telling them how much I respect them for their desire to serve their people under such scrutiny. They are truly finding their way in a man's world, so how can I complain about my own battles?

One month down

We've been here a month, one MONTH! Four weeks ago, it seemed like the time here would crawl. Now I know how fast it really will fly, and how hard it will be to develop, source and complete projects while we are here.

One goal we all have is to see at least one project through to fruition. I realize that sounds odd, but many of the projects that are being undertaken in the region are complicated engineering projects that take months to complete and often span the deployment of two or even three PRTs (provincial reconstruction teams). What can we complete prior to heading home? We really do not know.

The process for vetting and developing projects really rests in the hands of the local populace. They—with questions and prompting from our team of specialists—nominate projects to their elected officials, who then set priorities. We take it from there and work to develop what the people want. But change will be slow, as it should be. It took the United Staters many years to become the nation it is today, and Afghanistan should not be rushed.

On another note, we had our first “medical emergency” last night. We had just finished a quick mission to coordinate some election information when one of our soldiers closed his finger in a hatch on a truck. The hatch weighed a couple hundred pounds. We were unloading the trucks when the solder's buddies, staring at his smashed finger, began calling “Medic!, Medic!” Mind you, all the soldiers are trained in minor medical assistance but the first instinct is always to yell “Medic!” His fingernail was barely hanging on, so we numbed his finger and took the nail the rest of the way off. A quick X-ray showed a small fracture at the end of the digit but this, too, will heal.

I was happy to see that our first injury was somewhat self inflicted, and the girls and I were able to improvise some supplies and make do with what we had. One of my favorite sayings here is “Dance with the girl you brought,” meaning, learn to deal with what you have. It may not be perfect but you can make it work. To clarify, we soldiers are NOT short on supplies or equipment but, sometimes, what you use at home just isn't available and you learn to adapt and overcome. Having to improvise isn't mission failure but a chance to lean on your ability to think out of the box, and it only serves to make us better medics when we return home.

Enough, I am off to bed and looking forward to another day. You never know what it will bring.

First mission

Finally, all the stars align and I can blog about my Afghanistan adventures. I have been plagued by Internet connection issues, computer problems and just all-around business since arriving two weeks ago. I have so much to write about. I struggle with where to start!

I went on my first mission this week, and it was thrilling! I am happy to say we experienced no adverse events and considered the two days a complete success. We spent much of our time looking at our current engineering projects (several sections of road and some school projects) but my favorite part was playing with the children. The photo is of several children at one of our stops.

They were initially very shy but, once the camera came out, they all rushed to have a photo taken. The girls are all a little hesitant and tend to keep their distance but will creep closer as the boys become more engaged. I found getting them busy doing something with me helps break the ice. Counting was easy. I would try to remember the numbers in Dari, often getting them wrong. The children would laugh and try to teach me. I would also point at various objects and ask the word, then try to teach them the English equivalent.

The countryside is beautiful but barren. It reminds me a lot of southern Arizona, with beautiful blue sky and hidden canyons with flowing streams and trees. The living conditions are simple; often mud walls, few cars and true manual labor. We saw several wheat fields being harvested by hand and one area where the cows were being walked in a circle to separate the wheat.

I had the opportunity to meet with several doctors at the only hospital in our province, and they are very excited to work with our team. We hope to introduce a nutrition supplement for malnourished children at some point in our tenure here. It is a project that is having impressive results in other areas and the people of Kapisa would benefit greatly. There is also a physician training program here at the main base that incorporates didactic lessons with hands-on experience at all three international hospitals (American, Egyptian and Korean) and the providers were anxious to be recommended to the program.

We did have one medical emergency while staying overnight at a French base in the area. My counterpart who I am replacing (a physician assistant from California) and I were going to meet the French doctor for dinner. When we entered his clinic, we found him working on a local young man who had suffered a traumatic amputation of most of his hand. Somehow, he had put his hand into a thresher machine. The French team had stabilized him so, while my counterpart dressed the wound, the doctor and I called for help from the U.S. hospital. The goal is for the local providers to learn to care for their population, but this injury was so significant that we were able to send him to the American facility for surgery. We were thrilled to see this young man get appropriate care. It goes a long way to show the people of his village that we are there to help them.

This continues to be an amazing opportunity, and I look forward to the next nine months. I admit I miss my family terribly, but the time is flying by and, if the next 34 weeks go as fast as the first two did, I will be home before I know it. Nate and the kids are doing great and enjoying their summer travels—a much needed adventure to help their time pass quickly as well.
I promise to write more often, as long as the computer and connection cooperate!

I've arrived!

Hello everyone, and Happy 4th of July from Afghanistan! We left Indiana early afternoon on Monday and arrived in Germany to refuel in the early morning hours of Tuesday. After a short stop, we were again airborne and arrived in Kyrgyzstan that evening. Needless to say, the jet lag was horrible. We endured several required briefings, received our assigned follow-on flight for the next day and finally found the dining facility.

We ladies slept in a huge tent—the same size used for our dining facility in Indiana!—that held several hundred bunk beds. We were lucky! Fewer than 50 women shared the space with us and we all managed to get some sleep, but the jet lag kicked in and most of us were up within a few hours. Fortunately, there was wireless Internet and a 24-hour coffee shop, so we were set.

We left Kyrgyzstan the following evening (Wednesday) and arrived in a dusty, windy Afghanistan at dinner time. After enduring more briefings and collecting our baggage, we found our advance team waiting for us. We were so happy to see them and know our travels were over. After making a quick stop to drop baggage in our assigned “huts,” we went on a walking tour of our surroundings and found dinner.

It was interesting to observe our nation's birthday in a war zone. We celebrated by raising the American flag over our building and listening to a reading of the Declaration of Independence. We followed this up with a great barbecue hosted by the current unit. Now. it is time to get down to business as we continue to find our way around and talk to our counterparts on the current team. They have done an amazing job of managing their responsibilities in this diverse province, and we hope to do them proud as we continue their efforts.

Back in the heartland

So after a week of this:

And this:

And lots of this:

We had to do this:

The week was a blast and lots of memories were made to last us the next long nine months. I hated to leave, but Nate and the kids are doing great, are healthy and happy, so there's not much more I can ask for. They are off on a summer of adventure with an opportunity to see family and friends, which never would have been possible if I wasn't leaving for so long. After meeting up with the rest of my team here in Indiana, I am off soon for Afghanistan. It is an odd feeling: a small amount of fear of the unknown mixed with a lot of excitement and a readiness to get this mission started, so the clock can start for our return home. I promise more to come as we get settled and I learn more about our mission, roles and responsibilities.

Reconciliation

Have you ever had to reconcile two parts of your life? I am currently working to reconcile the need to become proficient in firing at least two different weapons with my calling as an NP. Not only will I be trained to use these weapons, they will become my constant companions for the next year, and I am expected to use them, if necessary.

I did not grow up in a hunting family, nor does my husband own a firearm. We never felt the need to protect ourselves that way. With our lack of experience with firearms and two inquisitive children in the house, we figured the risk far outweighed the benefits. I am not an anti-gun activist—and I do agree that people kill, not guns. I don't care if you own your own arsenal (although I question the need) but I just do not aspire to gun ownership.

As an NP, my job is to help and heal people, not inflict mortal wounds. We have already had the ethics lecture with the vignette depicting the need for triage between a minimally injured American soldier and a significantly injured insurgent. My answer, based on my responsibility to heal and the triage concept, was met with heated discussion from the commanders (all non-medical) about how they would argue to have their troop cared for first. Now, imagine getting back to base after a skirmish only to be presented with an injured enemy troop and discovering you were the one who had fired the offending bullet.

My analytical mind enjoys the challenge of target shooting and the puzzle of disassembling and reassembling a weapon. My desire to keep my fellow PRT members (and myself) safe from the “bad man” will motivate me to become as proficient as possible on all our weapon systems. But, the healer in me will continue to struggle and pray that I never have to pull the trigger on another human being.

Hey Doc, could you look at this...

As previously discussed, my role here is, first and foremost, senior medical provider. The senior part is just to make it sound important. In reality, I am the ONLY medical provider to members of PRT Parwan. I am lucky to have two very experienced and motivated medical technicians, but the buck stops here—with me.

The military is its own animal when it comes to using “mid-level practitioners” (a term I really dislike but it does clarify where we fit into the medical provider picture). In addition to nurse practitioners (NPs), there are also lots of physician assistants (PAs) to be found. And don't get me started on general medical officers (GMOs), medical school graduates with a single year of internship who, for whatever reason, do not enter a residency. They are sent to various assignments in physician billets but are not really qualified for that level.

We NPs continue to be licensed in our state of choice and we carry the required certification, depending on specialty but, within the walls of our military treatment facility, we practice fairly independently. We have full prescribing authority, are empaneled, have our own patients and conduct our own peer review. Some days, I equate it to hanging out a shingle and starting your own practice. I'm lucky. At home, I work with two great physicians who are ready and willing to answer my questions, or help me find answers when none of us have them.

On deployment, the independent practice concept can be taken a step even further. We NPs and PAs are often deployed forward of a hardened medical facility, where the physicians and surgeons stay, awaiting arrival of the really sick and injured. They are a phone call or Internet connection away, but there are no hallway consults. And, with luggage weight at a premium, our reference materials dwindle to what we can load into a PDA or find on a somewhat unreliable Internet connection. You quickly realize that explaining to every last troop what an NP does and what our unique role is is just more than they want to know. They want to know someone is there to take care of them when they are sick or injured, and “Doc” quickly becomes your accepted call sign.

Here at training, I am already getting the request to “take a look at this.” Thankfully, it is usually a sprained ankle, bug bite or, for many, the cold virus that has quickly spread among units (can't be helped when living in such close proximity). My goal now is to build confidence for when we are downrange and the concerns get different. Stress can reveal itself in many forms, including physical and mental fatigue, illness and even thoughts of suicide. As an NP, my strength for that “gut feeling,” when it comes to my fellow PRT members, will be critical, as mission preparedness can often equate to mission success. So, NPs of the world, never fear. I will continue to laud our strengths even while answering to “Doc” for the next year.

Why Afghanistan?

This is a question I ask myself most days. What is it all about? Why are we going? I have learned a TON in the last several weeks about the region, in general, and the long, tumultuous struggle the people have endured. They have been at war for the last 30 years—first the Soviets, then the Taliban and ensuing civil war, and now “occupation” by international forces. I use “occupation” in quotes as we are not there to fight the people of Afghanistan; we are there to liberate them from the Taliban. But some, here and abroad, see it as something else.

Who remembers that many of those involved in the attacks of 9/11 were from Afghanistan? Did you know Afghanistan has the highest infant mortality rates in the world? That nearly 80 percent of the population is illiterate? That just a few years ago, more than than 80 percent of the population lacked access to any medical care? That is why we are there. The long-term goal is to leave the people better off than the day we arrived (opposite the goal of those who came before us, when you consider the destruction caused by the Soviets and the Taliban).

So, why is a family nurse practitioner going? And what will I be doing to make the above happen? We—the members of my team and 11 other teams training here with us—are part of something called a Provincial Reconstruction Team (PRT). There are 25 PRT teams spread across Afghanistan, 12 manned by U.S. forces, 13 by other international teams. Our goal is to connect the Afghan people with their government and promote growth throughout each individual province.

In general, it is believed that the insurgents have an easier time manipulating people who are isolated from their govenment and countrymen, so our main responsibility is building roads. We don't actually do the manual labor; we have engineers on our team who help the Afghan locals bid and hire the necessary labor required to complete the job. Throughout the project, we return frequently to ensure adequate quality standards are enforced. We also partner with local leaders, physicians and educators to help meet the basic needs of the villages.

Prior teams have built schools, clinics and government offices. As a whole, the work done by American military and coalition members has enabled more than 50 percent of the population to have access to health care. Now, many more children—boys AND girls—have access to basic education.

I didn't really answer what I am doing, did I? I will wear several hats on this LONG trip. When you include training, it will be at least a year away from home! I am the senior medical advisor to the commander. As a senior ranking member, I also have some responsibility to ensure that everything, in general, runs smoothly. I will provide daily opportunities for our team to receive medical care, organize the necessary medical support for any missions off the relative safety of our home base and develop various medical outreaches to the local communities. In addition, I am constantly preparing for the worst-case scenario by training the entire team on how to respond to battle injuries and save their buddy, if injured. We want to leave in a year knowing we helped the Afghan people of Kapisa province, but our primary goal is to come home with everyone we leave here with.

As the coming year develops, I am sure there will be many more “hats” I will wear. Some days, I am the motivator, the one keeping the group moving forward on a five-mile march. Some days, I'll be the listener as lives back home compete for our attention. Some days, it will be my turn to struggle with the daily stress. Our team has a great sense of humor and lots of variety in skill sets, which will definitely come in handy.

So, readers, what else do you want to know about our upcoming job? About my role? Think I am crazy?