Col (Ret) Edward Fieg spent one of his multiple deployments as an embedded advisor to an Afghan hospital, focused on improving the nation's capability to care for patients. He shares his reflections on his time in Afghanistan and how the end of the Afghanistan war has affected him.
Read more about his time in Kandahar at https://drive.google.com/file/d/1mRbAjsyyFhvUItnFD53pg8LiZahWz-_O/view?usp=sharing
So where are you now? You're in St. Louis. Yes. All right. Was that a home for you? Or how did you end up there?Ed Fieg:
Well, this is where my wife is from, ah, right, trained at Barnes Jewish Hospital. And I was she's familiar with the area. SoUnknown:
we went to Wright State, and I was programmed to there for three years. And that wasn't enough. And so we had a chance for, you know, to be a bedside guy again, around department. So here I am. I'm at the VA. Fantastic. How are you liking the VA? Best best work I've ever done. That's awesome. And and we are so lucky when we have good Doc's that come there and really bring that level of service up. Well, the best is the veterans are really resilient. They're 13 and two, back to back World War champions. That's pretty good. It's very difficult to hire many of them. And they, they get riddled with disease, and they keep on chugging. It's amazing. Why don't you go ahead and introduce yourself and tell us a little bit about your background atrophy. Hi, my name is Ed Feig. I'm in St. Louis, Missouri. The Director of Emergency Department at John Cocker VA Hospital. I've been practicing for almost 40 years on boarded in both family and emergency medicine. And I spent 20 years on active duty in the Air Force, and did a wide variety of things, including two years on accompany Korea, about an 18 months in Afghanistan and seven or eight months in Iraq. So I've been around the block some well traveled and you and I ran across each other at Travis, when you were out there as a master clinician. That's right. That was certainly I think before you went to Wright Patterson. Good times. Yes. Excellent. Well, thank you, again, so much for coming in. And talking with us today, I really wanted to talk with you a little bit about those 18 months that you've spent in Afghanistan. And also, I just spent some time last week talking with Dr. Steve sample, who was a residency classmate of mine. And we both deployed to Iraq and Afghanistan, and spend some time reflecting on the differences between those two wars, because they felt pretty different to us. And so somewhere along the way, today, we may touch on that as well. Right? Well, I have tutorials on Afghanistan. The second one was mostly on a research team, but I was with a British in Bastion, and I worked in a trauma center for you know, about five, six months. But it was a previous deployment, which was unique, because that was a one year, remote outside the wire tour, embedded training team, embedded mentors with the Afghans. So that's the uniqueness of my expertise working with the Afghans because I was in their hospital. And working with them day to day, we live to a little fob that was right outside of the AMA base, which was near Kandahar. And I was in there every day and trying to help them, you know, stand up a combat support hospital. And that's for the tool fifth, and a core, which was a Camp hero in Afghanistan. And it was a very unique experience, the way they the way they practice medicine, the way they take care of things the way they think about things. And it's like, I mean, it's wildly outdated decades, and yet it's functional, and it is what they do, and it's how they do things. And I didn't they didn't work for me. I just gave advice and recommendations, but the little global the medical care in Afghanistan, particularly for not just only for the AMA for the soldiers, but also for the populace is very rudimentary. They have minimal access to physicians, there basically are no physicians. And the physicians that there are there are really very sketchily trained and have a medical system of medical schools or where did that where are those physicians coming from? They have medical schools so called there's at least one in country and but the the training standards are not recognized worldwide. And so it's pretty easy to get through medical school and like everything else in the country, there's a lot of corruption involved. But there are people who go through medical school and decide they're an orthopedic surgeon because they're interested in orthopedics and hang out a shingle and say I'm an orthopedic surgeon. So they really have no special expertise in it. They just have an interest in it. interest and that was that was true of of much of it but they The important thing is the, if anybody had any health care, it was what the AMA. And the Afghan National Army, Afghan national security forces had in place that we developed for them, that was part of the initiative to help build Afghanistan, the populace is, is much, much worse. And as I, as I alluded to, and that, and that thing I answered on the internet was, you know, these, they don't, they don't have medical problems, because they don't go to a doctor because they don't go to a doctor because they don't have a doctor. And, you know, their main problems are infectious disease and trauma. And both men and women life expectancy is about 45. So they never live long enough to get anything that needs a treatment. And if there was treatment, they couldn't afford the treatment, and they couldn't get the treatment. And if somebody had abnormal blood pressure, and that get 15 days of blood pressure medicine, and that's it. I remember that from taking care of local nationals when I was there in Bagram, a 50 year old Afghan was ancient. Yeah, you almost never saw them, they're like 90 or 100 year olds here. And they do not have, they don't have heart disease, they don't have cancer, they don't even have lung disease, because, you know, they, most of them don't smoke. But, but they do have malaria, they got parasites, and they have lots of trauma and lots of injuries and have access to a primary care physician, for somebody to deal with some of these things, is almost negligible. One of the things that you mentioned that you had sent me in the preparatory material for this was, you all were not allowed to care for any patients tell me about that? Well, we didn't have any direct responsibility, and the rule was never get between the patient and the Afghan physician or the Afghan healthcare worker, whoever it was, it turned out, we did care for a lot of patients, because there was no choice because we have multiple mass casualties and things like that, for the most part, you know, we were there, I was the only physician, there was a nurse there, there were some x ray techs, lab techs, you know, an administrator, kind of a pharmacist, but all we were trying to do was to give them advice and recommendations on how to run a hospital, how to equip it, how to supply it, how to staff it, how to process casualties, and, and, and try to help them with that we had an anesthesiologist, we had a nurse anesthetist for a while. So I mean, we had it was just kind of like a skeleton crew about 13 people of all the specialties. And we were their mentors. And we, you know, there are a lot of lot of anecdotes, a lot of stories I won't bore you with, but I'd be glad to send you my briefing stuff. But the way they did things, it's just, it's just, it's not what we do. Let's put it that way. I'm sure that was frustrating in a lot of ways to, to see that and hard to see that difference. It was very difficult to give advice when you knew they were doing the absolute wrong thing. And without offending them. At the same time, it was really, really, I don't want to say entertaining, but it's just stunning and eye opening. You know, you're just, you're, what they're doing. And but it's what they do. And it's interesting, because we really, here in the United States rely a lot on internet and communications. And we're hopefully making that leap from understanding and clinical research to clinical practice. I think I've seen a studies that said that usually the gap between when we see something in the literature and when it's actually in clinical practice used to be around 17 years, and we're hoping to narrow that down. It sounds like it's a lot longer there. Well, yeah, it's a lot of stuff. I was told, I don't know if it's true or not. But I was told a lot of stuff that's in there healthcare system came from the Russians, way, way back, and you know, decades ago, and they were still kind of practicing those kinds of standards from those days. And there were stuff that even I recognized that we stopped doing decades ago, but they were still doing it. Sure. You talked a little bit about how hard it was not to offend them. Tell me Tell me a little bit more about that and how you worked with the were you working mostly with the physicians, the administrators, how do you start to try to build a program that way? Well, that you know, I was the mentor for the physicians there was the nurse nurse mentor for the nurses administrator for them. And so we're all working together as a team and various, you know, various activity activities throughout the day. But most of it was you know, I'd go to their their sick call clinic with him. I was there in the emergency department when traumas came in and and I helped organize getting the help helicopters to land and, and brilliant patients direct from Kandahar. We take a team and go over to Kandahar with the Canadians and, and screen people right on the helo pad and put people on an Afghan ambulance and bring them straight over to the, to the AMA hospital. You know, obviously there were Afghans, somewhere civilian somewhere else ama or NP soldiers that were injured. But, you know, I mean, were they they're very diligent, they they want to learn, they want to understand how to do things, you know, they never done a lumbar puncture before didn't had no idea it was never put in a central line before they'd never, there's a lot of things they the more appreciative of as general anesthesia. And you know, this, the sanitary conditions and things that were how we sterilize things, all they had was a little dental unit that sterilize the instruments. Most of the instruments were Rusty, and they just kind of washed him down some alcohol. I mean, it was functional. That's how they tell they did it. And they took care of wounds very peculiarly. And so yeah, you don't want to they know what they want to do. And so when you give a little advice, and maybe you want to try this, but you want to try that, without there also there were a lot of civilians that would end up there in any hospital because they knew that Americans were there. And so they wouldn't be getting care in a in an Afghan Hospital, which is also very rudimentary. I mean, marijuana's Hospital, a Kandahar City, had an ICU, which was our reason was ICU, it had a bottle of oxygen. And it had one pulse oximeter that made the ICU. I mean, there was no there was no if there is no critical care, no ICU care at all, they just someplace to just stack people. And so some of the civilians would would learn about the base, and they would come straight out when their private cars or an ambulance and, you know, hoping to get care, I mean, a little kids with with retinoblastoma, and, you know, life threatening burns, you know, and, you know, for example, the, you know, the Afghan surgeons, they wanted to treat, a major burn, you know, full thickness, 70% burn and a kid with lasix. Yes, this kid needs lots of lasix. No, he actually needs fluids from Norway's Yeah, yeah. That must have been really difficult. And it's a little bit hard because we'd like to judge them based on our standards. And I remember, I remember when I was there, there was a child that was brought in that was incredibly sick. And earlier in the rotation, or earlier rotations before us, baby was born with hydrocephalus. And one of the neurosurgeons put in a shunt, and kiddo shunt got infected. And so they came back and they took the shunt out until the family, come back, you know, give them antibiotics, and then come back in a month. And we'll put it back in and they disappeared for almost a year. And then showed up during my rotation and brought in this child who had absolutely uncontrolled hydrocephalus, it was the most amazing thing that I'd ever seen. February of 105, obtunded, incredibly dehydrated, super sick child with ventricle itis at that point. And I remember conversing with a family through the interpreter saying, this child isn't going to make it, the best we can do is have you take him home and make him comfortable. And they said, No, you keep them, we'll go make we'll go we have others remember, wanting to judge that family, but then trying to remember that it's hard to judge another culture based on what we are. And I'm sure that probably happened a lot for you. Yes, it did. I mean, you know, they don't have the same western values. I think that's one of the main problems we have about trying to, you know, nation build and Afghanistan when people really don't want to be nation built, they don't want what we want. And, you know, we're kind of imposing out them because we think they would want what we didn't want, you know, they want water parks and free schools and McDonald's and they don't want any of that. So it was very difficult to to adapt to that culture. And of course, it's extremely religious culture. So they, everything that happens there is that somebody's fault? You know, I mean, nobody makes a mistake. It's all God's will. And if that happens, and inshallah you know, that's, that's, that's what, that's what they believe. And then and that's their, that's their culture. Yeah. Talk a little bit more about the things that you found in that culture, because you certainly lived it a lot more than those of us who were, you know, on a base by being more embedded in that culture in that in the civilian population. What things did you notice? about that culture, what did you learn about it? They have no problem with having 20 or 30 patients and inpatient, all inpatients in the hospital, some needing care, some not needing care, but some just boarding. But they have no difficulty just leaving them. I mean, leaving the hospital empty at night, and they they're going to bust that go back to the barracks. And you know, these people live in the hospital. And hopefully, they'll be fine in the morning or they won't be but it doesn't matter. They don't worry about it. I've heard that from other physicians that they would leave on, I think it was Thursday night, because if I remember correctly, Friday was their holy day. That's when he come back two days later, and whoever was still there, he took care of them again, Saturday is better Monday and Friday is there, you know, our Sunday, and they would take off on Thursday night, Friday was to holiday. And sometimes if there was a holiday, I mean, like a real Muslim holiday, they'd be gone for weeks. They'd go back to their their home. And we wouldn't read where'd they go? Why they went home. I mean, they just it's really kind of frustrating, because you're trying to, you're trying to build something, and it's, it's, uh, you know, it's like one step forward, and two steps back to get them to, you know, try to take ownership and have work ethic and pride in what they're doing. But they just, they did not, it just really didn't have I mean, some did, of course, and some were very, very enthusiastic and wanted to learn and want to study. I mean, a couple of surgeons, we helped I talked to one I'm just a few days ago, in fact, I've talked to several of my interpreters, three of them, I got back, I'm working on three others to get them back, especially immigrant visas. And some of them back here for years. But I talked to a surgeon who was there was basically self trained, you wanted to be a surgeon, so he learned how to do it. And he's now the the the Medcom, commander of the defunct now defunct AMA, but he's in, he's in Kabul, and he's kind of a big shot. And he's, he's trained himself, and he's certainly a lot of other doctors. So, you know, inch by inch, you know, journey. 1000 miles starts with the first step. And, and they were doing that pretty much so well, and I, we were probably about the same 100 and 150 years ago, and we've had so much opportunity to grow, and hopefully their time will be a little shorter, to get to where what we think of as, as the the way that medical care should be, should be done. Yes, it's very challenging. I mean, it's almost like the Taliban, you know, they want to live in the seventh century. And that's what they want to do. And they're happy as a clam doing it. And I mean, they have running water, they don't have heat in their homes, they don't have. And, I mean, they have the Qur'an, they have their families, and that's all they need. And for them to try that now, that intelligentsia, of which there are many, educated and interpreters, they're smart enough to know they have to get out. And that's exactly what to do. So the people who could build the country are leaving in droves. I remember thinking that in Iraq as well, that the the people that are needed to rebuild a country after that type of war, have either fled or been killed and who is left to rebuild? That's a that's a hard question. Exactly. You know, and I think what you were talking about with people, just going home at the end of the day really puts into perspective, our staffing shortages here in the United States. Right here in the middle of COVID. We we are struggling with nursing staffing. And so far, we haven't just left the hospital empty yet. No. I mean, our culture is to help everybody as best we can all the time. And that's what we do. And, you know, we don't want anybody to suffer anybody die unnecessarily. You know, is it perfect? No, but over there, they're really pretty comfortable doing exactly what they want to do. Refugee Health Care is an entirely separate topic. But can you talk a little bit about taking care of Afghan patients and and things that you've learned that can help us all do better when we run across these patients? Well, the one thing very sensitive is the women. The women cannot be examined by another man, it's, it's virtually impossible. And number one, they won't allow it. And number two, they don't, they wouldn't. They'd be very offended if a man tries to do an exam on a woman. And we had some of those are pretty dicey and trying to find a female physician or any kind of female provider. And, and that's not just you know, we think of I'd like to have a female for my pelvic exam. That's just heart and lungs. That's any type of exam right? do anything even to touch them, you can't even can't touch them, you can't look at them, you can't dress them. Everything is you know, they take offense to it theoretically. So that was always very challenging. The the physique, mostly a linguist, the interpreters were all physicians, so called trained in Afghanistan, they're all pretty smart guys, they had they could speak English pretty well. But their their understanding of medical care, likewise, you could tell because I can communicate with them directly. And they would interpret for me with Dad lectures regularly every week. And, you know, there's most of the stuff they didn't know. They're very smart guys, there's educators, you can be in Afghanistan. And one of them is to one's an EMT, over here, now paramedic, he's in Houston, and other one is a is a nurse who's in Virginia. Another one is a as a think he's a blue collar worker and in, in Buffalo, but you know, none of their care is recognized from Afghanistan, if they had the papers, when they come over here, I'm right now I'm working on the urologist. They're really good guy. He was, it was a good surgeon. He came from, from, from Kabul, from the National Military Hospital. And they would come down to Kandahar for a few months of time to go back. So his brothers in California, were trying to get him back. But he has like, as most families and Afghan Afghanistan do, they had eight children. That's the average number of kids, one family. So you're trying to come back with a wife and a children. And he's, you know, probably in his 50s. They don't know their age, by the way, I'm presuming you're aware that they have no idea what they're when their birthday was or when so they're all born on the first of January. So we actually had something very funny about that one of my medics when I was there, because we, you know, we need to patient identifiers for all of our computer systems. So we had trauma names, and then we would guess how old they were. And we would use that as the date that they you know, you looked about 20 years old, so we subtract to 20. So you were born in 2001. And then the date of your injury, or the date you were admitted was your month and your day of birth. And one of my medics had no idea that was going on and said, Isn't it terrible that all these Afghan patients are getting hurt on their birthday? I said no, that's not how that worked. Very funny. All right. It's just a guess. They don't recognize their birthday. And so yeah, it's hard to guess. But they have to have a birthday to function, United States. So most of the ones I know are all the first of January and some random year. And ironically, I'm on Facebook with all these people, and I get all these birthday notices for the first birthday. So anyway, oh, that's, that's another kind of a stumbling block. But anyway, the these guys are the expectations. Well, I'm a physician, I'm in practice for 20 years, I'd come back to the states and I'll be a doctor here. Well, that's virtually impossible, you're gonna have to find something else to do. And you have to start over. And it's, it's a, it's, it's gonna be extremely difficult. You talked a little bit about health care of women. And I actually had an interest, I had several interesting experiences that I'd like to mention for the female physicians out there. Because males often did not want to be examined or cared for by a female physician. And we sometimes see that but I remember very clearly, one time, my one of my colleagues who was a female anesthesiologist was trying to excavate someone and was trying to tell him to cough and take a deep breath. And so she would, she was trying to get the interpreter to teach her how to say, take a deep breath in, I believe it was dari was the patient's language. And she would say, tell me how to say it. And the interpreter would tell the patient and she said, No, I want you to teach me and he finally told her, You are not allowed to give a patient a you are not allowed to give a male instructions or commands. And I still remember that so clearly as again, that culture mismatch of gender dynamics that we didn't even think about. Yeah, it is very peculiar. And I just saw a news news brief that they asked the guy who is the so called President or whatever, of Taliban said, How come there's no women in government? How come you don't have women involved in your thing? And you know, aren't half the population women? And he said, he said, We don't consider women to be people, you know, they're not part of the government. You know, women stay home and make babies. And that's pretty much it. I think that's one of the hardest things about watching this all happen because Even while we were there, I was there in 2013, women were still very much a part of that society that was not allowed to join in too much. But girls were able to go to school, we did see some women in the hospital, not working, but they would come in for medical care. I am very sad and think that that is probably going to change a lot, and that those women who had those opportunities that's now gone. And yet, it is their way it is their culture. And it is worth the is what the Quran tells them. And Sharia law tells them, and that's what they're going to do. And unfortunately, that's not the worst of it. The worst of it is probably the, you know, the repudiation of the people who break those rules. And what's what's going to happen on a large scale. I mean, there's no question I did they did it before. Yeah, I mean, they're, I mean, you know, only one in five Afghans can read and write. They can't read, have no, they, you know, their complete mercy of, you know, they're in the desert and their environment and what they do, and they're trying to keep their family alive, keep it fed, and, you know, try to keep from against going from warring against the the warlord is down the road, a couple of kilometers. And that's their life. It's very much a different culture. It's, it is very much a warrior culture, still, but the pinnacle of what you can do is fight for your tribe. And I think it started to change a little bit with some of the things that we did, but it is hard to change millennia of history in 20 years. Yes. And there are, as you know, there are many different backgrounds, they're not all half cancer, all kinds of things are Tajiks, their Pashtoon their diary their Uzbeks, there are I mean, it's the culture is full of, and they're frankly, they're kind of a racist people very xenophobic, or people who are not like them. And that causes a great deal of strife and angst inside the community. And I mean, it's some extent, you know, we experienced the same thing with stuff in United States, but over there, it's, it's much more amplified. And, you know, people who are not the same nationality and in the one tribe in Afghanistan, are generally not regarded in the same as a Pashtoon would and with a group of Pashtuns. I think that's really important. And something that most people who haven't been part of this conflict and deployed there don't understand. Because we think of the Afghan war as a war against a country, just in a broad sense, and Afghanistan, politically, as seems to me at least much more multiple different tribes with a very loose association based on geography, like you and I will identify as you might be in St. Louis, but you're still an American, and would still claim that as an identity. But most Afghans, Afghan as an identity is very low on their list of things that they would say that they were, if it's even on the list at all, that that loyalty is much stronger to family and their tribe or village than the country. And it's, and so instead of one Afghan war, it was really 10,000 Tiny wars, with a whole bunch of different hormones. For people that are seeing these patients that are coming into the country, what are some of the common things that you're going to see in these Afghan evacuees, malaria parasites, I mean, not just not just worms, but I mean, worms that have, you know, consumed the liver, or the colon, or the heart, and, you know, and they, they still have, there are still people who have, you know, rheumatoid arthritis and things like that, that, you know, they're crippled with, but they have no diagnosis of, but I think it'd be gonna be really challenging for people to, to receive these refugees. And, I mean, I know what's going on on the basis, you know, there's, there's a field hospital and all these places, and they're coming in, you know, with I got this, I got that I got this. And hopefully, most of it's functional, but there are still going to be people with, you know, birth defects and, and, you know, some some cancers and things like that. There. There are going to be there and especially in little kids. Yeah. So, I remember for local nationals at Bagram whenever we'd have somebody come in, like your admission order set. We gave everybody I'll bend dizzle It was always kind of a fun trick to play on the new anesthesiologist to not tell them that apparently they asked her iasis really disliked the inhaled anesthetic gases, and would start crawling up and out of the nose. And so that would always freak out the new anesthesiologist if you didn't tell them but that was a really common thing when these patients would go to the operating room to have those roundworms starting to come out. The other thing that I remember was a really big issue we had to deal with was malnutrition. And for these big trauma patients who were already very malnourished trying to get them nutritionally optimized so that they could heal from their big traumas was a really big challenge. Yeah, curiously, there's a very little HIV. I mean, they just it's not that kind of a culture, you know, I mean, they're, the men are not exposed to women. And they're exposed to each other, but they're not exposed to outside man. So you know, there's there's not a lot of that rarely see somebody with hepatitis, usually it's hepatitis, a infection hepatitis, but there are, you know, there's a lot of drug use a lot IV drug use a lot of heroin, especially in western Afghanistan, but that's the main source of finance for the Taliban. And it's still a huge, huge industry, for them, and that's how it fuels their, their activities. I also remember seeing patients that would come in that it had remote traumas that didn't heal correctly. I remember we had one gentleman that had had a leg fracture had a looking at the X ray, that must have been a TIB fib fracture, and healed it a really unusual angle. So his foot was almost 90 degrees from where it should have been. Yeah. And it was really kind of fascinating to see that. Yeah. had healed. It didn't do hot, but it's there. Yeah, ah, we did see we did see some of that. Some bronchopleural, Catania fistulous. Some people with the, you know, shortcuts, syndrome, bowel obstructions, stuff like that for being shot in the past. The, if somebody lost a limb, if you lost two limbs, you've lost if you lost two legs, in mortality in six months was like 100%. There was just no way even though the wasn't the stumps that you nobody could take care of you. And, you know, their bed rest the whole time until they were, you know, pressure altered on stage four, and it gets infected and that's how you die. Yeah, there's just little altar you do. There's no prosthetics. There's, you know, very minimal type stuff like that. You mentioned, female physician, by the way, there was a female position of Chief of Surgery, in fact, and Mary's Hospital in Kandahar City who we used to have conferences with her. She was amazing. And she curiously, she was extremely well respected. There's not another words. And she could speak English. And she was, I'm not sure what her training was. But they did like eight C sections every day in that hospital. cluttered like three or 400 babies a month. And she was one it was doing all that stuff. And I don't know where she is now. But I remember she she was famous, you know, and they respected her curiously, and had no intruder like a woman, I guess. And because she was she was a surgeon. Interesting. Everybody knew who she was. And she came out the any hospital from time to time and well, and I think that's probably a an important point to think about, too, that for the Afghan women, we expect that they are probably going to have very poor health care, because there are so few women physicians that were allowed to care for them. So any type of GYN care, any type of women's health care issues, you should probably expect that they just weren't addressed. No. It's very, extremely minimal. I remember one of my ophthalmologists that I was deployed with. Early on in our deployment, we took care of a child about a four or five year old that was involved in a backpack bombing. Somebody left a backpack in the middle of the market. And he had a huge eye injury. And so my ophthalmologist took him to the OR multiple times and and throughout that time that we were there he worked with worked trying to get this kid glasses because after his eye injury, obviously his eyesight was really quite poor. And I remember as they were trying to figure out how do they get these glasses made? Because that's not something that the Americans brought over there was the ability To make lenses and tests for all of this stuff, and about towards the end of the time that we were there, the glasses finally came in and you want to talk about coke bottles, those things were like bulletproof glass thickness. And when that kid was finally put them on, he was able to walk. And I remember talking with Mark, and he said, I'm not gemologist I don't save lives. But I saved that kid. Because the difference between being able to see well enough to walk without somebody guiding you, and having to be led everywhere you go is literally the look difference between life and death. Because there's just not enough. Yeah. Yes. Yeah, it was funny. The, I mean, you think a lot of the Afghans need glasses, I'm sure they do. And, and at the, at the NA Hospital, where I, where I was, there was some kind of I never forget this device, it was like a, it was a thing that would automated would take a prescription for eyeglasses. And all I needed was a technician push a few buttons and a prescription would come out and we'd send it up to Kabul, and, you know, a few weeks later on a an Afghan transport and some glasses would show up, and people would put them on. And no idea how accurate it was. I had no idea if it helped. But it was funny because we had to they did have a machine there that would, you know, give you a lens prescription that my guess is probably just, you know, that ground lenses, but they're just you know, general thing. You're there to read or I don't know. Interesting. Any other tips? I remember one of the things that kicked off this entire conversation between you and I was your Facebook posts talking about stop calling them Afghanis. Yeah. Yeah, you know, people keep doing that. Because, you know, people know Pakistan is they know Iraqis. And so they think, you know, Afghanis are people from Africa, but their debts, that's actually what they call their money. That's the currency. And so I know, it's just one of those things. It's a little bugaboo that every time I hear somebody having a president does it, they do it on Fox, I've been writing letters to foxes, how would you please tell the talent to stop using the word Afghans? It's, you know, it's it's ignorance. You know, they're not Afghanis. So anyway, they're getting better at it. I've noticed. In fact, I had one, one of the one of the commentators once on one of the new shows, oh, I didn't mean to say afghan. That's the currency. I'm sorry, I apologize. Afghans. Maybe that was one of my letters. sent in to the to the producers, but But I mean, it's such a little thing that we we giggle about, but it's important. It's important. And a sign of respect for these people. Yes, very much. So. You know, this was a question that a patient of mine actually asked me a few weeks ago, and it kind of caught me off guard. It was right when everything was about ready to happen in Kabul. And he asked me, What do you remember? What do you miss about Afghanistan? And it kind of set me back on my heels, because everybody likes to ask about, you know, did you see people die? Yes, I was in the emergency room. Of course, I saw people die. Did you kill anybody? And I'd say no, I tried not to, at least not intentionally. But that was a question that I never been asked before, which is what did you miss about it? So that's my question for you. Well, I would say, do the Afghans was absolutely the highlight of my career. And when I was on the ground with them, I mean, I don't know if you remember the article it was put in in the McCord newsletter, but I mean, I was, I was Edward of Kandahar, I was trying to read that in your thing, and it was too blurry. So I'm gonna have to find the link and I'll drop that link in the show notes. I might have a copy somewhere else in here. But basically, it's just that day and night, every day, there was something to do something happening, somebody needed something and it was just constant, you know, and I mean, you're, you're away from home, you're living in a shack, and you have nothing else to do, but to go to work. And you have your team and you try to put things together, you don't have a lot of resources. And so just solving problems and, and trying to get from day to day and teaching somebody something and, you know, my team I used to, I used to try to lament that, you know, it seemed like, what Afghanistan needs is a reformation you know, and someday somebody is going to come along and they're going to stop all this you know, this, you know, religious secularism, you know, this non secularism. And maybe that moolah who's going to do that is the son of somebody, you're going to try to help, who's, you know, shot up blown up or something like that. And if you, you know, if he has a life he may have, he may be the great grandfather of somebody who does that and reforms that culture, because that's what it's going to take. As there's no other way around it. It's so it's so parochial, it's so biased. And, you know, they I think you're right. I think we knew in 2013 it was, and I'm sure you probably knew when you were there, too. That's most of that country was just biding their time until we left. Yeah, it was a blast been really was. It was a very, very unique opportunity. I know it was tough, especially being gone that long. But I'm I am. I've often said that. It is so hard to be gone. But deployment is the best, best professional experience I've ever had in my life, by far, certainly helps you appreciate what we got back here that most Americans will never ever see. Yes. The advantages that we have are, it's hard to imagine a world so different. What do you think the legacy of what work? You did? There will be? Do you think that those things that you shared in that hospital will bear fruit? What do you think that's gonna look like? Well, I don't know. I mean, there were several team, there was a couple teams came after us and one team before us trying to set up the hospital. I have no idea what's going on there now. But I know, we did try to help people to learn and how to understand how things work and, and some of them moved on to Kabul, but what they what the Taliban is going to do with all this AMA, I presume the whole system is defunct now, and how these people are going to survive and earn a living and feed their families. You know, I mean, that's pretty much everybody talks about, you know, why did the Afghan army fold so fast when we were getting ready to leave? I mean, they were early an army there was just like a militia. They're like a ragtag group. It was. It was a it was, it was almost basically a jobs program. And in Afghanistan, you only had a couple of choices you either during the NSF, or you join the Taliban, and you, you know, you pick poppies. And that's the way you feed your family. One of those two things, he joined the NA the ANP, or he joined the Taliban. It's not it's just business, it's not personal, that it's not nationalism, they just just, they just need money. I think you're exactly right. And again, that's looking at it through our American lens and not realizing that you're right. That's pretty much what's available there. And now what now what are they got? They got nothing. I mean, I don't know if they're gonna go back the way it was 2030 years ago, it's my guess. And there's probably going to be a civil war. And, you know, warlords are going to take up arms against the guy down the road. And it's gonna be terrible, I think. Yeah. And hard to know that we left that some of those people that helped us are still there, you worry about them. Yeah, I worry about them a lot. And, you know, like I say, I hear coming out of the woodwork finding me because they're trying to get back. But I think it's amazing that we're willing to take people who weren't necessarily, you know, contractors, for the coalition, but they're just people in the community that went out. And so, I mean, it's gonna keep going, it's gonna be a lot of people that are gonna want to come back. And I think that they'll probably assimilate, they'll probably figure things out. But it'll be entirely different from what they've ever seen before. Yeah, I think it's very sad for the future of Afghanistan, because as we talked about before, all of the people with the skills and the tools needed to rebuild that country are currently fleeing. That's right. And they will take that culture and those skills, and then all of the good things that they could have in Afghanistan, or that they could use to rebuild Afghanistan, and take those to other places. And we get to hopefully be the lucky recipients of some of that. But it's, it's sad to know that their country misses out on that. Yeah. And it's a paradox too, because that that country is rich with natural resources. And they could I mean, if you could go over there and, and, you know, mine the lithium and mined the copper and everything else. I mean, it's just, but they don't understand it. They don't know what it could do for him. They don't, they don't know get it. And that's, I think that's very important. They are happy in the ways that they have been living for millennia and Maybe it's not our place to tell him, but it should be different. Yeah. You've now you're taking care of patients in the VA Health Care System? And have you seen any changes any impact on the VA patients that you've been taking care of on the veterans over what's been going on the last few weeks? Well, that's been talked about, and it's been, we've got a lot of briefings on it. And probably at some level, I have not personally seen people, we don't have a lot of young people, very few. Most of our veterans are all over 65, probably 75 80% of our patients in Emerg. Department are elderly. So you know, they're Vietnam era Korea era, very rarely World War Two, there are some younger guys, but, and a lot of mental health problems, obviously, drugs and alcohol. But I haven't really seen anybody articulate that they're upset about, you know, losing a limb or, you know, coming back with PTSD for a cause that, you know, is now defunct. I have not personally but but, but they're talking they're talking about it there. There's all kinds of programs to have, you know, veterans who are feeling that angst to be able to call in talk about it, you know, usual kind of, you know, support groups and things, but personally, I have not seen it. I know I reached out to the the people that I was deployed with, as this was all coming down, because you right, it felt it was definitely very sad to see that work, fall apart. But I think that most of us have shared that. That feeling especially getting to be on the medical side of we get to wear the white hat just about anywhere we go. We don't have to be the shooters we don't have to make those hard choices. We just get to care for people. And that that's a little bit easier, I think. Yeah, it's a lot of us blood and treasure. And international blood and treasure went right over the dam and fantasy fantastic. This is fantastic. We took a step back in time. How are you doing with it? Well, I'd worry about the people are over there. And that my friends and and I was I was working on a I was gonna take some leave and I was gonna fly llama BOD Pakistan rent cargo across the border. I had it all worked out to do that my wife was to my ears is if you do that outbreak all your fingers. I'm guessing she wasn't excited about that idea. Yeah, you know, it was shoot out and but I found one of my interpreters, the the paramedic from Houston. He was in Cabo. And he was trying to get his family out. And he did successfully. And they're all scattered all over the world. But they're all out. But I just felt like I had tried to do something. And I didn't know what it was, but but I wanted to try to I think I could have pulled it off to the truth. Except for your wife. She would have had something to say. But anyway. Yeah, it's it's very disquieting. I think that's a common feeling amongst a lot of us. And we certainly saw that that a lot of different veterans groups stood up and worked to help people get out. Yeah. And I think there's it's an interesting and telling, feeling that we all have to want to say we're not quite done yet. We're still willing to help. Yeah, yeah. I think probably are probably involved in the care of probably 2000 casualties altogether 500 Level One traumas. When I was a veteran, and just the limbs and in the bin of, you know, not just not just us, US servicemen but Afghans just it's just so pathetic when you realize all the resources were involved and all the expenditure and and all the people that got maimed and killed. It's like, why did we do that for what we thinking? And we probably went is we're so common to do so are so fun to do is to go overboard a bit like Clark W Griswold and say, Okay, let's, let's build a Walmart here in downtown Kandahar City, you know, so, no, I think you're right that those of us who have gone to the trauma hospitals and had those types of deployed experiences, when we come back out here into the real into the civilian world. I remember we had a rollover MVC where somebody lost a limb lost an arm, oh, it's been a year ago or so. And here that's a once in a lifetime type The injury that you see. And there's a lot of physicians here in the United States that never see that. And that's just what we did. every three hours. It wasn't just every day, some days it was multiple. I remember I was taking care of a patient who had like a hand, Blackie he'd crushed his hand with a forklift with forks of a forklift. So I was selling him up. And they brought a nine line to me about a patient that was coming in and I was selling and I kind of was reading over my shoulder and I said, Oh, that's just a foot amputation. We don't need to run it as a trauma, it's no big deal. And the patient that I was working on said, just a foot amputation, that's not a big deal. And I said no around here, you got to lose two or three before we even get excited about that. And it's definitely a a, an experience that especially the ER Doc's that deployed, it's a very different experience and, and even a different experience than what the gsts and the the people that are going out now with this new generation of war, now thinking that my two wars are our past. And the new conflicts that our military physicians are going out on now. They're much different. Certainly seeing some significant trauma but not in the not in the volume that we saw. Yeah, you're right. I'm sure the generation before us was likewise different from what we saw. Yeah. I remember, Jim path, that was one of my attendings down at Vamsi he said that he actually volunteered to come back on active duty and wanted to deploy again, because they said, I can't teach these residents to do this kind of medicine in a war that I haven't been to. And I still remember that and remember respecting him tremendously for volunteering to go over to see exactly what we were doing. And we certainly I've learned a lot and I think emergency medicine, I don't think I know emergency medicine has changed tremendously because of what we learned. But it's strange to be part of that history evolving. Yeah. Any other thoughts or anything else that you'd like to share? I've taken a tremendous amount of your time today, but I've really enjoyed having the chance to talk. No, I think it's, I think people, you know, would benefit from knowing the stories and, and hearing the things that went on and, and just get an idea that, you know, it's not the same as that's not the same as something that goes in different part of the world. And it's going to be difficult and there's gonna be a lot of there's gonna be a lot more angst a lot more horror, unfortunately. And until it all settles down and and it's got to be we got to do the best we can and one day after another and, and try to take care of people as best we can teach people as best we can. And maybe one day it'll all work out.