Recent Fleet Marine Force pinning ceremony for our surgical technicians and our independent duty corpsman:

Fleet Marine Force Qualifications

On November 10, 1775, in Tunn Tavern, Philadelphia, Samuel Nicholas was commissioned to raise two battalions of Marines. As the Marine Corps. first commandant, Samual Nicholas was tasked with raising a Continental Marine fighting force for the protection of combatant naval vessels as a young nation sat on the cusp of a full British invasion (not The Beatles; the other invasion) mere weeks before the signing of the Declaration of Independence by our forefathers.

Not only were the Marines charged with protection of the ship at all costs, they were also responsible for protecting the officers from mutiny. Hence, Marine berthing was smartly placed between officer and crew berthing spaces in those early days.

With over 300 amphibious landings to their name, the Marine Corps has been serving proudly for well over 200 years. Considered shock troops by most Countries in the world, the Marines are both revered and feared at the same time, and as the only fighting force born in a bar: it's no wonder the Marine Corps. has never backed down from a good brawl.

As Navy personnel attached to a Marine unit in Iraq, we had the unique opportunity during the deployment to immerse ourselves in all things Marine Corps. At times, it seemed like an endless process of classes on tactics, weapons, communications, structure, history & tradition, aviation, ect. We wore our uniforms to Marine regulations, completed six mile "humps" in the desert with our gear, and followed all USMC physical fitness standards while serving the greater Anbar region as the Ar Ramadi surgical team.

Below are some of the pictures of our recent pinning ceremony for the officers. After completing exhaustive sign-offs over five months and enduring hours of questioning and challenging our knowledge by a panel of Marine Corps. Officers, we earned the right to wear the Fleet Marine Force (FMF) warfare device with pride and distinction.

RH, our detachment commander~affectionatly known as "Blue"

Back Row: Martin, Bob, Mark, myself, and Chad

Middle: Sgt. "Mac" and LT Brown from Evac platoon

Kneeling: Dave

KBR and Team Blinky

D squared: "First the fan seems to shift into a lower speed regardless of temperature setting. Then it makes some funny noises. Before we know it, the hut temp starts rising despite our attempts to crank down the controller to 16 degrees celsius. The inside temp has been climbing into the 80's and now 90's in the afternoon. We try to shift modes into "fan only" and we have also started pouring water on the outside condenser to cool it off; it sits in direct sunlight all day. Well, anyway the fan eventually shuts off and the unit goes from a red light and starts blinking "red".
Two KBR HVAC "experts" have responded to our trouble call tonight. One guy is outside grabbing some tools, and the other is standing in our hut looking at the A.C. unit and listening intently to D squared explain our problem. He's giving the appearance of using active listening skills, and nods at all the appropriate pauses, just in case we think there's a breakdown in communication.
After D squared gives an exhaustive and thorough explaination of our woes, the second KBR guy comes in. KRB number one looks at him, and as we lean forward expecting keen insights and nods of understanding, maybe a few "Ah, Ha! Elementary, of course" moments...he simply states "Blinky, Blinky" to the second guy. KRB guy number two gives a solumn and grave nod, wincing as he displays deep knowledge of the "Blinky, Blinky." It's going to be a long afternoon...

The ensuing week brought both insight and bemusement to how KBR HVAC guys work. Most are from Turkey, and we have a hard time communicating with them. I have a harder time understanding where the credentials came from. Several "teams" show up on various days to fix our AC unit and compressor, each with their own brand of comprehensive HVAC know-how:

Team Blinky comes in with the standard assumption that our unit is low on freon and just needs a charge. Out comes the compressed freon, a few hoses and gauges, and "presto" Team Blinky is convinced our unit is running like a top. It's midnight, and we try to tell them "sure, it seems to work now. It's been cooling down for hours. Why don't you come back, oh, say around 2 PM tomorrow afternoon." Big smiles from Team Blinky as they just want us to sign the service order so they can get out of there. I don't think they get it.

Team Two comes the next day and announces "All those other guys put too much freon in these things. They run so inefficiently and never last. You just can't over-pressurize these units." He proceeds to bleed out around 80% of the compressor's freon for better or worse as he quips "Wow! Did you see that stuff spray out of there? Don't let em' see you do that in the States'!"...noted.

Team Three comes two days later. Hut temps are ranging in the low 100's during the day, and our modest digs are now rendered useless. Half of us move into a tent, and the other half move into the operating room. Team three's preconceived notion: those filters are always getting clogged, and no one cleans them right. They spend two hours straightening drain hoses and cleaning the filters that were just cleaned within the week. "We clean filters. Good now. You sign right here, it's OK." Turns out: not so much...

We complain loud and long enough, threatening to shut down the operating room, that KRB agrees to put in a bigger 3 ton unit. After six days, a little progress.
So, the HVAC supervisor comes out for a site survey and to figure out why team after team has failed to recognize that our unit is just plain out of commission. He's even more amusing to talk to than Team Blinky:
Supervisor: "these things are breaking down all over the place. They aren't even designed to work in the heat."
I'm struck by the paradox, but it gets better as Eric suggests we move the new compressor to the side of the hut where it's shaded 80% of the day.
Supervisor: "What? That would ruin it! No good."

"The shade? No good? How is this possible?"

We go round and round looking for clarification on exactly why shade is bad, yet the A.C. units aren't designed to work in the heat. Nothing coherent is forthcoming...not that I expected it.

Dilemma

"Just what am I supposed to do with this patient?"

"It's not my call to make. Don't know what I can tell you beyond circumstance and treatment."

"Well, was he doing anything before he was intubated?"

"He came in intubated, so we don't have much of a baseline to go on. He seemed to have some upper extremity movement and looked like he was miming a fish's mouth when we lightened anesthesia to attempt to wake him up. I think he's got some outside chance of a recovery, so we wanted to give him that chance."

"Alright, well I know it's not your fault. I just wonder what we are going to do with this guy."

This was part of the conversation I had last night with an ER physician in Balad. Our patient was an Iraqi civilian that decided to gun towards an IP checkpoint, and held heavily armed men in low regard this afternoon. For some reason, this is a common occurence. Civilians really like to speed close to convoys, get their vehicles lodged into convoys, and just plain not pay attention to big signs that read 'STOP, CHECKPOINT AHEAD" or "STAY BACK, DEADLY FORCE AUTHORIZED" in Arabic. From what I gathered from our interpreter, this guy was unarmed, not suspected of being an insurgent, and just wasn't very good at following instructions while wielding a 2 ton weapon on wheels.
As he barreled towards the checkpoint, he was shot in the neck and subdued. We heard about him when it happened, because he was originally supposed to come to Charlie Medical. Instead, we aren't really sure what transpired over the course of the afternoon, but we knew he was Ramadi General-bound. Case closed. Or so we thought....
We commandeered an entire table for dinner, and the surgical team was sitting down to chow. Up runs one of the surgical techs looking for us. He was told by Charlie Medical that indeed the patient was again coming to us, but Ramadi General had him in surgery. Well, this didn't make much sense. We'll roll with whatever comes, so we finished up and started back to medical to wait for his arrival.
Our detachement commander gets a call on his cell. The patient just arrived, is intubated with gastric contents in the breathing tube, and he is obtunded (not arousable). Bob sprints ahead now to assess the airway situation and find out why a previously stable and "in surgery" patient has mysteriously shown up at the door a suddent train wreck.
He quickly assesses that somehow the patient was improperly intubated. The breathing tube was inadvertenly introduced down his esophagus instead of the trachea. However this happened, we now have a patient with a stomach and bowels filled with a whole lot of air, and none to very little in his lungs. How did it happen: don't know? How long has he been deprived of oxygen: don't know?
He still has the gunshot wound to the neck that hasn't been explored or repaired yet, so we rush him to the OR. All major structures intact except some cervial vertebra damage, Martin does the exploration, cleanout, and is closing the wound within an hour.
Which now leaves us with a huge dilemma to sort out. With a superficial and seemingly easily recoverable neck wound, we now have a patient on our hands that is one big question mark. He seems to have been deprived of oxygen for some length of time. It is obvious that he currently has deficits; we tried to wake him up after surgery, but it wasn't happening. With these types of injuries, it is impossible to know what the outcome will be. What function and cognitive ability will he regain? 50%? 80%? The only way to realize what the outcome will be is to give it time. Weeks to months of time....and that is why we made the decision that I would fly him to a bigger hospital. Somewhere with CT scanners and a neurosurgeon on staff. The only place in the Country where he has any chance whatsoever. But we also asked a lot of Balad last night, too. We are asking them to accept the burden of initial and secondary care, giving up limited resources, to a patient that may or may not recover. They accepted, as all of the caregivers out here, to have the patience to see him through, no matter the outcome. Like us, every day they press the "I believe" button and just go with it.

Like my patient, Iraq is a wounded Country. As with a brain injury, there's no quick prognosis and no quick fix to Iraq, either. Standing where we stand, there is no crystal ball to gaze into and give us all the answers. You'd be better off looking for starfish in the Mississippi River. So we have to ask ourselves what will give us the best chance for a secure Iraq? Citizens free to go to the marketplace without wondering if they just palmed their last pomegranate waiting for the place to go up in a fireball. Without Iran and Syria squeezing from the borders like a nerfball in a vice. I don't purport to have all the answers, but I'm intimitely aware of how all wounds heal....with time and patient support.

Incognito to 180-Out

I'm actually sitting here in front of the 'post entry' screen. It's felt like such a long time, and I have been thwarted in so many ways. I'm lucky I still remembered how to log in...

I'll start by laying out a small littany of excuses for my most inexcusable absence: I no longer have internet access, which means a trek down to the internet hut and waiting for a terminal if I want to check email or post an entry. For one reason or another, every time I have had a chance to come down here, it's either been shut down for service, shut down for maintenance, or just a general sense of desert apathy.

I have also been consumed with earning a warfare designation since June. Navy personnel attached to Marine Corps units have the option to follow Marine Corps regulations if they so choose and stand before a panel of Marine Corps officers to show their knowledge of doctrine, tactics, history, organization, weapons, tactics, ect. A few of the officers and all of the enlisted team members have been dedicated to this task for months, and included living, eating, and breathing Marine Corps. The officer board was held recently (we all passed, somehow) and our enlisted board will be held by the Command Master Chief within the next few days.

But, by far, the most noteworthy information I have to share is the current state of Ramadi's security. A stark contrast to what we saw in February when we arrived in Anbar, Ramadi is now one of the top success stories coming out of Iraq in the past six months. Iraqi Police have been working hand in hand with our units in and around the surrounding Province, and attacks have been virtually non-existent for weeks on end. The media has also keenly picked up on our successes, and have been reporting that Ramadi, and the cooperation and open exchange of information with local Sheiks we have enjoyed, should be the model considered for transforming the unstable, hold-out Provinces left in the Country.
Next month, our leadership will be answering some tough and pointed questions about the authorized surge force that started arriving in February with our surgical team. A portion of the surge is here in Ramadi and the surrounding Anbar region. And with this surge, we have seen dramatic change and success. However, general consensus is that even though the surge certainly had some positive influence to the security of Ramadi, most of the credit goes to the Anbar Awakening and local clans and Sheiks aligning with us against Al Quaida and other insurgent elements.
Sure, the extra Marine units didn't hurt, but the influence of having 20,000 local Iraqi men in uniform patrolling the streets, manning all checkpoints, and setting up curfew and roadblocks in and around the entire city warped us almost instantly into an atmosphere of calm.

In five short weeks, the replacement surgical team will be here. After unit turn-over, we will begin the journey back to Kuwait. Destination: home. The change here in Ramadi, and indeed all of Anbar over the past seven months has been amazing. Totally unexpected, but worth witnessing many times over: almost complete security from utter chaos. 180-out.