curlycorday

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For those of you considering military medicine, read this article. Don't listen to the outspoken majority that are probably specialists wishing they could make 5 times as much money in the civilian world. Listen to what doctors with a real passion for what they do say:

"So, when asked, “How was it?” We can confidently say it was one of the most rewarding experiences of our lives. We were able to practice our neurology specialty to make a difference both in the war effort and in our individual patients’ lives. We were able to practice general medicine and make contributions that were much greater than in normal, day-to-day practice. But, better still, we had the honor of taking care of the most deserving patients anyone could find anywhere: the American soldier at war defending the principles of freedom, self-rule, and equality that define the United States."

THIS IS WHAT ITS ALL ABOUT FOLKS! wake up...
 

curlycorday

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Citation for quote above for the gunners who will call me on it:

Ling, G. and Maher, C. U.S. Neurologists in Iraq: personal perspective. 2006. Neurology 67(1): 14-7.
 
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curlycorday said:
For those of you considering military medicine, read this article. Don't listen to the outspoken majority that are probably specialists wishing they could make 5 times as much money in the civilian world. Listen to what doctors with a real passion for what they do say:

"So, when asked, “How was it?” We can confidently say it was one of the most rewarding experiences of our lives. We were able to practice our neurology specialty to make a difference both in the war effort and in our individual patients’ lives. We were able to practice general medicine and make contributions that were much greater than in normal, day-to-day practice. But, better still, we had the honor of taking care of the most deserving patients anyone could find anywhere: the American soldier at war defending the principles of freedom, self-rule, and equality that define the United States."

THIS IS WHAT ITS ALL ABOUT FOLKS! wake up...
Curly;
I agree with the article and the principles stated. As somebody who believed military medicine, specifically Primary Care, is in shambles, I still believe there are areas of military medicine that "get the job done (well)" and areas that physicians can find great satisfaction and give great care. Military medicine IS NOT 100% terrible top to bottom. HOWEVER, I witnessed first hand things that promote poor patient care and poor staff retention that you would NEVER see in civilian medicne.

So, I agree that your example is a good example of "what its all about folks" but that is NO EXCUSE what what is going on stateside.
 

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Anyone got a password to access the article. I'd love to take a look at it.
 

militarymd

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curlycorday said:
THIS IS WHAT ITS ALL ABOUT FOLKS! wake up...
That's right!!! THIS IS WHAT IT IS ALL ABOUT!!!!

The only problem is that the leadership in military medicine DOES NOT know it.

The bureaucracy and clip board COW manders who interfere with WHAT IT IS ALL ABOUT is EVERYWHERE in military medicine.

Don't join.

Let it die.

Make them fix it so that it CAN BE what It is meant to be.
 

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Nice article. Thanks for sending it out RMD.

(there's more on the way....)


U.S. neurologists in Iraq: Personal perspective
Ling, Geoffrey MD, PhD; Maher, Cornelius MD, PhD
From the Medical Corps, U.S. Army, Department of Neurology, Uniformed Services
----------------------------------------------
It didn't seem real until that nighttime helicopter ride. Lights out, machine
guns up, and skimming a mere 50 feet over rooftops at over 150 miles per hour.We were en route to the Combat Support Hospital (CSH) located in Baghdad at the frontline of the Global War on Terror. That is when we came to the full realization that we were joining a long line of neurologists going to war with U.S. forces that stretches back at least to Dr. S. Weir Mitchell, who joined the Union Army during the Civil War. In 2005, it was our turn-one of us in the spring (figure 1) and the other in the fall (figure 2).
Why send neurologists to war? Simply, neurologic disease is found everywhere, including the modern battlefield of Operation Iraqi Freedom. Among severe battle injuries, head wounds lead. Even among non-battle-related injuries, neurologic causes are common. Headache, seizure, neuropathy, alteration in mental status, and back pain are as frequent in this community as elsewhere.

It began with a phone call-one that put the rest of our lives on hold. With a
couple weeks' notice, we had barely enough time to find clinical coverage,
cancel appointments, and hug our families. Our odyssey officially began at the
Continental United States Replacement Center or CRC. Here, we were issued three duffle bags full of equipment. Notably, we each got weapons-typically a 9-mm pistol and/or M-16 plus full "battle rattle": a helmet, armored vest with ceramic plates, holster, and the other accoutrements of the properly attired military physician. Next all doctors were re-educated on being soldiers: how to protect a convoy, don a gas mask, and establish a defensive perimeter. Some courses were quite good. We learned about local Arabic customs, indigenous fauna to avoid, and "don't drink the water." Some lessons, such as basic first aid, were less useful to us. We were all required to qualify with our weapons. This entailed proceeding down a path and shooting at (and hitting) pop-up targets.
After medical and dental screenings, checking our life insurance policies, and
verifying our wills, we were shipped off to Kuwait. There, we were separated
into common final destination groups. Ours was off to Baghdad.

Since returning from deployment duty in Iraq, we have been asked, "What was it like?" Simply put, it was both good and bad. The bad parts seemed relatively minor in the more global view of why we were there-to take care of wounded American soldiers. Although we were not "at the tip of the spear" on patrol with the troops, the CSH was in a war zone. We were reminded daily that this was not home. We were required to carry our weapons at all times, including when on clinical rounds. Whenever we ventured out of the hospital, we had to be in full battle rattle (figure 2).

To the uninitiated newcomer, this may have seemed excessive. That is until the first experience of the boom and ground shaking associated with an explosion. Incoming mortar shells occasionally disrupted clinical rounds. Even the local outdoor market where we shopped was destroyed by a suicide bomber. At such times, no one hesitated to don battle rattle. The equipment was hot and heavy, but at the same time, remarkably effective. Without a doubt, this equipment is saving lives. Some unsung heroes of this war are the material scientists who invented it. The soldiers believe in it, and so do we.

Another reminder of the distance from home was the dust. Dust everywhere. Dust not like sand at a beach but rather like talcum powder. It got into everything-laptop computers, clothes, and toothbrushes. Another reminder was the heat. When we first arrived, it was so bright and the heat so intense that we felt like we were on another planet. An air temperature of 125 [degrees]F is oppressive, regardless of how dry it is. Being in battle rattle only exacerbated this. We were amazed that our troops are able to perform so efficiently under such severe conditions.

Without a doubt, the toughest part of being deployed was being away from our families. E-mail helped as letters from home were almost real-time. If it were not for missing our families, most of us would gladly have stayed longer.

"Dear Soldier" cards from schoolchildren and goodie packages from well-wishers were sources of comfort. These kindnesses, especially Girl Scout cookies, were shared and deeply appreciated by everyone.
 

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(...this should be it.) Enjoy.

Retrospectively, the bad parts seem insignificant. The best part was the
practice of medicine. At the CSH, everything goes except basic medical
practice-"taking care of the patient." No matter what one's specialty, when at
war, we are general physicians first.

The CSH was busy! On a typical day, 15 to 60 trauma patients would come through the emergency department and up to 100 through the clinic. For only 30 physicians, this was an extraordinary patient load. While most of the practice of war medicine was trauma care, there was constant and significant nonsurgical care. The majority of our patients fit the latter category.

The defining sound for military physicians is the sound of an inbound helicopter. Since the Korean War of the early 1950s, dependence on air ambulances has increased. Images conjured by the opening sequences of the television show MASH seemed appropriate to our hospital. We will never forget the "whump whump whump" of helicopter rotor blades that could be heard throughout the hospital. Medics rushed out to the landing pad and offloaded up to eight patients at a time. On a busy day, helicopters were constantly landing or taking off, and it was not unusual to have 10 to 20 critically injured patients come in at a time, many with tourniquets over missing or mangled limbs and actively being resuscitated. At such times, we neurologists acted as general physicians, doing triage, compressing a wound, or starting a central venous line.

For a neurointensivist, i.e., neurologist who practices critical care medicine,
work in this type of hospital was an opportunity to use all of his/her critical
care and neurology skills. It began in the emergency department, assisting in
initial assessment and resuscitation. The emergency medicine physician, who
orchestrated the initial clinical care, depended on the active participation of
all physicians regardless of specialty. But while everyone helped, it was
valuable to have someone who was comfortable managing hemorrhagic shock,
ventilatory failure, and invasive procedures including endotracheal intubation.
Patients who did not require immediate surgery were taken to the intensive care unit (ICU). Here, care continued, including intracranial pressure monitoring and mechanical ventilator management. For neuro-patients in the ICU, the primary physician was the neurointensivist.

For optimal care of the critically ill neurologic patient, close coordination
between neurosurgery and neurology was necessary. A highlight of deployment duty was being able to work in an environment that was so conducive to collegial practice and mutual respect with our neurosurgical colleagues (figure 3). Their contribution to caring for casualties cannot be understated, and the neurosurgeons we served beside did heroic deeds routinely.
---------------------------------------------
For example, on one busy evening, six neuro patients were brought in. The most seriously ill had an open head wound with exposed herniating brain. He was taken immediately to the operating room. The other five patients had head wounds to spine injuries. Each required evaluation and treatment; one would also need neurosurgery. While the neurosurgeon was operating, the neurologist managed the other patients. This meant suturing a head laceration, reading the CT scans, and medically resuscitating the others. It also meant going into the OR to confer with our neurosurgical colleague to determine specifically what was and what was not operable. In the end, all did very well.

Beyond the ICU, we also practiced traditional general neurology. Each day, 50 to 100 outpatients came to the CSH. Many were referred to a neurologist by a military unit's physician or physician's assistant. Often our important task was to determine who was able to return to duty. A field commander needs adequate numbers of able-bodied troops. Medical decisions as to mission readiness had to be made quickly and decisively.

Patients were referred for neurologic assessment for many disorders. The leading cause was headache: migraine, tension, and even cluster headaches. Serious conditions such as arteriovenous malformations, stroke, or subarachnoid hemorrhage were sometimes discovered. Soldiers who could be treated successfully with simple interventions, such as a triptan, were sent back to duty. Others needed to be evacuated from the war theater.

One particularly vexing condition was postconcussive syndrome. Mild head injury was common, with causes ranging from a simple bump when exiting a motor vehicle to exposure to an explosive blast. Overwhelmingly, such patients had headaches. Other symptoms included impaired concentration, difficulty sleeping, or anxiety; however, headache remained the primary reason for seeing a neurologist. Typically, nonsteroidal anti-inflammatory drugs were used. Failing that, a triptan might be used if there was a migrainous component. If the headache was atypical, an antiepileptic drug such as gabapentin was tried. Impaired concentration was assessed by traditional mental status examination and very simple neurobehavioral testing. If impaired, such patients were hospitalized for bed rest. Treatment success or failure had to be determined quickly, often within a day or two, or else the patient had to be evacuated from theater. Such decisions had major consequences to the soldier's unit and were thus done with appreciation of the military operational consequences.

Alterations of consciousness were a leading concern. The overriding issue was
whether or not the soldier had suffered a seizure and, if so, whether an initial
event was a harbinger of epilepsy. EEG, MRI, and even antiepileptic drug levels were not available. Medical decision-making was largely dependent on neurologic examination, history, and CT as these were the only neurodiagnostic tools we had.

Acute changes in mental status presentations ranged from loss of consciousness and loss of awareness, to psychosis. Often, these changes were related to trauma, metabolic or infectious etiologies. Alcohol and drug abuse were relatively rare. Alcohol use, including beer, is forbidden to all U.S. forces. Sometimes, patients needed referral to the psychiatrist.

In the war theater, the practice of neurology is at its most fundamental level.
Patient care is all that matters. The usual concerns of regular life-committee
meetings, paperwork, traffic jams, a parking space too far from the front
door-vanish. Our patients were special to us. The American soldiers we took care of were proud of what they were doing. They were determined and committed. Almost everyone wanted to return to duty.

One particular case was a patient who suffered a fractured spine after being
thrown from a vehicle struck by an explosive. When he was told that he was going to be sent home, this young soldier cried and begged us to let him stay. When told he was a hero and had nothing to be ashamed of, he told us that here he was doing something truly important, helping people who are trying to build a free and just nation. His example of nobility was one of many.

So, when asked, "How was it?" We can confidently say it was one of the most
rewarding experiences of our lives. We were able to practice our neurology
specialty to make a difference both in the war effort and in our individual
patients' lives. We were able to practice general medicine and make contributions that were much greater than in normal, day-to-day practice. But, better still, we had the honor of taking care of the most deserving patients anyone could find anywhere: the American soldier at war defending the principles of freedom, self-rule, and equality that define the United States.
 

chopper

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curlycorday said:
For those of you considering military medicine, read this article. Don't listen to the outspoken majority that are probably specialists wishing they could make 5 times as much money in the civilian world. Listen to what doctors with a real passion for what they do say:

QUOTE]

Didn't you mean outspoken minority?

Freudian slip?
 

IgD

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Chopper, I read it to mean the outspoken majority in this forum who are critical of military service.

chopper said:
curlycorday said:
For those of you considering military medicine, read this article. Don't listen to the outspoken majority that are probably specialists wishing they could make 5 times as much money in the civilian world. Listen to what doctors with a real passion for what they do say:

QUOTE]

Didn't you mean outspoken minority?

Freudian slip?
 

chopper

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IgD said:
Chopper, I read it to mean the outspoken majority in this forum who are critical of military service.

As I'm sure you would. I still think it is funny, intentional or not, to use this language. One normally speaks of an outspoken minority. Then, you can use language like 'they are a minority with an axe to grind' (I think this is the basis of your arguments over the last year). An outspoken majority, well . . . . . maybe they really have a point then.

And I totally agree that being at the pointy end of the spear is WHAT IT IS ALL ABOUT. This doesn't mean that I don't feel the leadership in the military is doing a good job. Far from it.
 

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IgD said:
Chopper, I read it to mean the outspoken majority in this forum who are critical of military service.

So IgD, when are you leaving for the sand? Or is that one of the things you talk large about but don't ever expect to have to do?

All we've had from you is you shaking your pom-poms.
 

IgD

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I was wondering the same thing about you. I wanted to ask you some advice about the military since you are obviously so knowledgeable and successful. Is it okay to talk about that sort of thing here or would it be a violation of operational security?

orbitsurgMD said:
IgD said:
Chopper, I read it to mean the outspoken majority in this forum who are critical of military service.


So IgD, when are you leaving for the sand? Or is that one of the things you talk large about but don't ever expect to have to do?

All we've had from you is you shaking your pom-poms.
 

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IgD said:
Chopper, I read it to mean the outspoken majority in this forum who are critical of military service.
I don't think any of us are critical of military service, but most of us are critical of military medicine.

Is it a violation of OPSEC to provide any evidence that you're anything other than a recruiter?
 

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For those of you considering military medicine, read this article. Don't listen to the outspoken majority that are probably specialists wishing they could make 5 times as much money in the civilian world. Listen to what doctors with a real passion for what they do say:

"So, when asked, “How was it?” We can confidently say it was one of the most rewarding experiences of our lives. We were able to practice our neurology specialty to make a difference both in the war effort and in our individual patients’ lives. We were able to practice general medicine and make contributions that were much greater than in normal, day-to-day practice. But, better still, we had the honor of taking care of the most deserving patients anyone could find anywhere: the American soldier at war defending the principles of freedom, self-rule, and equality that define the United States."

THIS IS WHAT ITS ALL ABOUT FOLKS! wake up...
07-21-2006 06:25 PM

This is an interesting account of the war—very idealized and PR friendly. It would be an excellent recruiting tool. I am glad that the authors had a rewarding experience in the Iraq Theater, however, I recently returned from duty at a CSH in Iraq, and would like to provide a somewhat different perspective.

The major support hospitals have now been up and running long enough that most of the administrative shenanigans that go on at stateside hospitals have metastasized to Iraq. Far from being “all about patient care,” there is increasing focus on administrative issues—by which I mean pointless meetings, paperwork, and glad-handing VIP’s. For example, in Iraq I wasted 1-2 hours a day at meetings where we reviewed Power-Point slides of hospital “metrics.” We had clipboard nurses who did no clinical care and wandered the wards talking about (I am not making this up) whether or not we were JACHO compliant.

One of the major concerns of our Hospital Commander (instead of the broken CT scanner or the inadequate OR supplies) was the fact that the surgeons were, “Out of uniform all the time!” It seems that when paged in the middle of the night to take care of mangled soldiers, the surgeons were rushing to the hospital in their PT uniform and failing to take the time to put on the full BDU. Plus the fact that the surgeons had the unmitigated gall to wear scrubs around the hospital all day (surgeons in scrubs! What nerve!). During the rotation before mine, the hospital commander was removed from his position when he was caught sleeping with his vice-commander within the hospital complex on more than one occasion.

I would guess that it stopped being “all about taking care of the patient” around late 2004. For many people, it’s now more about buffing your OPR for that O-6 promotion board.

I’m happy that the writers had, “the most rewarding experience of their lives,” but I wonder why the rest of their clinical existence is so unrewarding. Personally, I feel that I am saving a soldiers life every time I fix an AAA or perform a carotid endarterectomy. The only difference is that these soldiers fought in WWII, Korea, or Vietnam. I had a guy in my clinic last week with a large AAA who survived the Battle of Bulge and spent the entire winter of 1944-45 sleeping outside in the snow. I found treating him just as rewarding as any operation I did in Iraq (most of which, incidentally, were on Iraqis). Why do guys like that deserve any less than the guys in Iraq? These days they can’t even get a primary care appointment without two weeks of phone calls and hassle.

I don’t mean to impugn the motives or experience of the writers, but I find this sort of account to be very simplistic and self-promoting. Nice PR for the army medical dept. but adds nothing of substance to a discussion about the quality of military medicine in war time or peace time.
 

orbitsurgMD

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IgD said:
I was wondering the same thing about you. I wanted to ask you some advice about the military since you are obviously so knowledgeable and successful. Is it okay to talk about that sort of thing here or would it be a violation of operational security?


Dr. IgD, is it?

I will assume it is. My mini CV is on the creds thread, page 1, to which you have as yet been unwilling to contribute. Why only you know. I served before, during and after Gulf I. I did the SWA AOR x3 then. I am civilian now.
 

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mitchconnie said:
This is an interesting account of the war—very idealized and PR friendly. It would be an excellent recruiting tool. I am glad that the authors had a rewarding experience in the Iraq Theater, however, I recently returned from duty at a CSH in Iraq, and would like to provide a somewhat different perspective.

The major support hospitals have now been up and running long enough that most of the administrative shenanigans that go on at stateside hospitals have metastasized to Iraq. Far from being “all about patient care,” there is increasing focus on administrative issues—by which I mean pointless meetings, paperwork, and glad-handing VIP’s. For example, in Iraq I wasted 1-2 hours a day at meetings where we reviewed Power-Point slides of hospital “metrics.” We had clipboard nurses who did no clinical care and wandered the wards talking about (I am not making this up) whether or not we were JACHO compliant.

One of the major concerns of our Hospital Commander (instead of the broken CT scanner or the inadequate OR supplies) was the fact that the surgeons were, “Out of uniform all the time!” It seems that when paged in the middle of the night to take care of mangled soldiers, the surgeons were rushing to the hospital in their PT uniform and failing to take the time to put on the full BDU. Plus the fact that the surgeons had the unmitigated gall to wear scrubs around the hospital all day (surgeons in scrubs! What nerve!). During the rotation before mine, the hospital commander was removed from his position when he was caught sleeping with his vice-commander within the hospital complex on more than one occasion.

I would guess that it stopped being “all about taking care of the patient” around late 2004. For many people, it’s now more about buffing your OPR for that O-6 promotion board.

I’m happy that the writers had, “the most rewarding experience of their lives,” but I wonder why the rest of their clinical existence is so unrewarding. Personally, I feel that I am saving a soldiers life every time I fix an AAA or perform a carotid endarterectomy. The only difference is that these soldiers fought in WWII, Korea, or Vietnam. I had a guy in my clinic last week with a large AAA who survived the Battle of Bulge and spent the entire winter of 1944-45 sleeping outside in the snow. I found treating him just as rewarding as any operation I did in Iraq (most of which, incidentally, were on Iraqis). Why do guys like that deserve any less than the guys in Iraq? These days they can’t even get a primary care appointment without two weeks of phone calls and hassle.

I don’t mean to impugn the motives or experience of the writers, but I find this sort of account to be very simplistic and self-promoting. Nice PR for the army medical dept. but adds nothing of substance to a discussion about the quality of military medicine in war time or peace time.

Mitch,

What an excellent review. Its unfortunate that some would label you defective or unpatriotic for saying such blasphemy that most true doctors lived everyday in military medicine. Although I was never deployed, I can concur with this by personal experience from at least 3 surgeons I worked with who were deployed, and had much of the same complaints, except they did not get to do much surgery. I'm sure I've posted this before, but for 4 months one of my friends became an epidemiologist to find out who the index care of VD was in the camp. What a waste of resources. Unfortunately much of the same will continue, and it people like idg who promote such mediocracy that will keep running the system into the ground where hopefully it will be so bad that it has to change.
 

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many of the clipboard nurses and commanders are nowhere to be seen until.... the discovery channel or some drama documentary crew show up... then they start placing IVs and taking blood pressures for the camera and fake like they are all involved in patient care to get on TV.....the vice commander that the commander was sleeping with was a pretty ugly lady too....
 

militarymd

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former military said:
many of the clipboard nurses and commanders are nowhere to be seen until.... the discovery channel or some drama documentary crew show up... then they start placing IVs and taking blood pressures for the camera and fake like they are all involved in patient care to get on TV.....the vice commander that the commander was sleeping with was a pretty ugly lady too....
I was there when it started....on ships....same thing as on the sand.....The organization is a cluster f**k......major diservice to the people who are getting hurt.
 
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mitchconnie said:
This is an interesting account of the war—very idealized and PR friendly. It would be an excellent recruiting tool. I am glad that the authors had a rewarding experience in the Iraq Theater, however, I recently returned from duty at a CSH in Iraq, and would like to provide a somewhat different perspective.

The major support hospitals have now been up and running long enough that most of the administrative shenanigans that go on at stateside hospitals have metastasized to Iraq. Far from being “all about patient care,” there is increasing focus on administrative issues—by which I mean pointless meetings, paperwork, and glad-handing VIP’s. For example, in Iraq I wasted 1-2 hours a day at meetings where we reviewed Power-Point slides of hospital “metrics.” We had clipboard nurses who did no clinical care and wandered the wards talking about (I am not making this up) whether or not we were JACHO compliant.

One of the major concerns of our Hospital Commander (instead of the broken CT scanner or the inadequate OR supplies) was the fact that the surgeons were, “Out of uniform all the time!” It seems that when paged in the middle of the night to take care of mangled soldiers, the surgeons were rushing to the hospital in their PT uniform and failing to take the time to put on the full BDU. Plus the fact that the surgeons had the unmitigated gall to wear scrubs around the hospital all day (surgeons in scrubs! What nerve!). During the rotation before mine, the hospital commander was removed from his position when he was caught sleeping with his vice-commander within the hospital complex on more than one occasion.

I would guess that it stopped being “all about taking care of the patient” around late 2004. For many people, it’s now more about buffing your OPR for that O-6 promotion board.

I’m happy that the writers had, “the most rewarding experience of their lives,” but I wonder why the rest of their clinical existence is so unrewarding. Personally, I feel that I am saving a soldiers life every time I fix an AAA or perform a carotid endarterectomy. The only difference is that these soldiers fought in WWII, Korea, or Vietnam. I had a guy in my clinic last week with a large AAA who survived the Battle of Bulge and spent the entire winter of 1944-45 sleeping outside in the snow. I found treating him just as rewarding as any operation I did in Iraq (most of which, incidentally, were on Iraqis). Why do guys like that deserve any less than the guys in Iraq? These days they can’t even get a primary care appointment without two weeks of phone calls and hassle.

I don’t mean to impugn the motives or experience of the writers, but I find this sort of account to be very simplistic and self-promoting. Nice PR for the army medical dept. but adds nothing of substance to a discussion about the quality of military medicine in war time or peace time.

Very nice response.
Why don't you send it in to "Neurology" as a letter to the editors?

X-RMD
 
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