Checking Sugar

The thin 55-year old man looks older than me. His name sounds Chinese and he does not speak much English. Per his triage sheet, he wants his blood sugar checked.

 "Why do you want your blood sugar checked?"

"I did not bring medicine to Palau."

"When did you come to Palau?"


"Five years."


"Oh. Okay. Are you diabetic?"


"I did not bring medicine to Palau."


"Okay. Got that." (So I'll do an actual history, looking for symptoms of diabetes.)


"Have you lost any weight?"


"Nine pounds."


"Over how long a time?"


"When I came to Palau."


"So you've lost 9 pounds in five years?" (Hmmm. I've lost and gained and lost and gained again three times that much weight over five years...)


"I did not bring medicine to Palau."


"Right."


"Are you thirsty? Hungry?"


"I drink much water and always hungry."


"Over how long a time?"


"I came to Palau five years ago."


"Right. Do you urinate a lot?"


"When I drink water I urinate."


"Okay. Any moreso recently?"


"I came to Palau five years ago."


"Okay. So, again, why did you want your blood sugar checked?"


"I did not bring medicine to Palau."


"What medicine?"


"Don't know."

"Blood sugar medicine?"

"Don't know."


"Right. Do you have any other symptoms?"


"Weak."


"How long?"


"Since I came to Palau."


"Right. Along with the nine pound weight loss?"


No answer. The man looks puzzled. Not as puzzled as I feel. I see that his blood glucose was 412. That would be high if it was a fasting blood specimen.


"Did you eat anything before you came here today?"


"Big breakfast."

"Right." I do a quick exam. He's thin, but no muscle weakness and no physical signs of diabetes.


"Okay, so the blood sugar we did doesn't count because you ate first. It needs to be done again when you are fasting, I mean when you haven't eaten since the night before. You can come back here tomorrow morning and we'll do it again. Or you can do it at the hospital. But we can't give you any medicine until we know what that fasting level is. Then there might be some other tests that need done. You would have to get those at the hospital." (I've seen the Palau Hospital. It's a good place. Much like a small rural community hospital in the States.)


"Okay."

I write out an order for a fasting blood sugar. He very pleasantly shakes my hand and thanks me.


We are running a free clinic in Palau this week as part of Pacific Partnership. Guess this man got his money's worth. On the other hand, if seen by a civilian practice in our country, the exact same episode would have racked up a healthy fee for "Office Visit, Initial."

Not sure I understand the value there.

Liberty Boat Night

FADE IN:

EXT. PALAU FLEET LANDING - NIGHT

After a day of work ashore and a light dinner and drinks, DOC, LOGGIE, and SEAL board the 2200 liberty boat with a dozen other sailors to return to Mother.

FADE TO:

EXT. PALAU FLEET LANDING - NIGHT, LATER

Senior Chief announces a boat ops delay due to rough seas at Mother's anchorage. All but DOC, LOGGIE, and SEAL disembark the liberty boat.

FADE TO:

EXT. PALAU FLEET LANDING - NIGHT, STILL LATER

As curfew approaches, more Sailors and Marines arrive at Fleet Landing and head to the bar. DOC, LOGGIE, and SEAL stay in the liberty boat.

CUT TO:

EXT. PALAU FLEET LANDING - NIGHT, LATER

Senior Chief announces indefinite hold on boat ops. Some Sailors and Marines head back into town. DOC, LOGGIE, and SEAL remain on liberty boat.

FADE TO:

EXT. PALAU FLEET LANDING - NIGHT, EVEN LATER

Still no boat ops. DOC, LOGGIE, and SEAL stretch out on liberty boat benches to catch some sleep.

CUT TO:

EXT. PALAU FLEET LANDING - NIGHT, LATER.

Sudden rainstorm abruptly awakens DOC, LOGGIE, and SEAL on board liberty boat. They get very wet. DOC goes to head.

FADE TO:

EXT. PALAU FLEET LANDING - NIGHT, LATER

Rain stops. DOC, LOGGIE, and SEAL stretch out again. Sleep.

CUT TO:

EXT. PALAU FLEET LANDING - NIGHT, LATER

Rain starts again. They get wetter. DOC goes to head.

FADE TO:

EXT. PALAU FLEET LANDING - MIDNIGHT

Rain has stopped. Senior Chief announces suspension of boat ops until 0600. Sailors and Marines are free to go back into town to get hotel rooms. Muster again at 0600. DOC, LOGGIE, and SEAL remain in liberty boat. Stretch out to sleep.

FADE TO:

EXT. PALAU FLEET LANDING - NIGHT, 0230

DOC, LOGGIE, and SEAL asleep on liberty boat benches. Awning above suddenly dumps a few gallons of water onto the deck. They get very wet. DOC goes to head.

FADE TO:

EXT. PALAU FLEET LANDING - DAWN

DOC and LOGGIE sit in liberty boat, heads in hands. SEAL nowhere to be seen. Other sailors board boat. Pilot starts engine.

SMASH CUT TO:

EXT. AT SEA - DAWN

Liberty boat races through ever increasing swells, bouncing like a skipping rock. Driving rain peppers riders like pellets of hail. Cresting each swell the boat goes momentarily airborne then smashes into the next swell causing torrents of sea water to crash over the sides, drenching the occupants. Suddenly Mother comes into view. She is only 300 yards ahead, rapidly getting closer when...Pilot suddenly turns boat around and heads back to Fleet Landing. Just not safe to continue.

FADE TO:

EXT. PALAU FLEET LANDING - JUST AFTER DAWN

Liberty boat returns and ties up to pier. Twenty dripping sailors disembark, DOC and LOGGIE with them.

DOC

It wasn't even single malt scotch.

DOC goes to head.

FADE OUT

Engaging a Class Act

For those who wonder what a Fleet Surgeon without patients to see really does to earn his pay, the answer is that I engage.

As one of my persistent priorities, I develop partnerships with my medical counterparts in other militaries across the western Pacific. I recently completed a very rewarding engagement with one of our premier partners, the Republic of Singapore Navy (RSN). Much like the nation they support, this Navy and its medical team is a highly developed, sophisticated, and competent enterprise. I enjoyed a rewarding several days of ship and hospital tours, culminating in a live afloat exercise involving medical evacuation (MEDEVAC) of a simulated patient off a U.S. ship onto an RSN frigate for emergency resuscitative surgery. Forward resuscitative surgery on small operational platforms is a new capability under development by both navies. Testing the concept at sea is an important step in that development.

The day began with helo transport via a Singapore Air Force Chinook to the deck of the Tank Landing Ship (LST) RSS Persistence. I joined several U.S. and RSN Flag officers in observing an operational exercise associated with the annual CARAT (Cooperation Afloat Readiness and Training) between our two navies. Upon conclusion of that event, our medical team boarded an FCU (Fast Craft Utility) boat for the short sea transfer to the frigate RSS Steadfast where the medical exercise would take place. (The LCU resembles those landing craft featured in "Saving Private Ryan".) The conclusion of the transfer involved an engaging ascent up a road ladder hung over the side of the ship. How many civilian docs ever get to do that?

Soon the U.S. Navy HS-60B Seahawk arrived on the flight deck with simulated patient on board. The RSN medical team demonstrated superior acumen and professionalism in triaging and transporting the patient mannekin from flight deck to hangar bay to the medical centre, which is a one-room resuscitation/treatment area similar to what we have on our own smaller vessels. These treatment rooms are not designed for surgery, hence the cutting edge nature of this exercise. The RSN team executed the drill with flawless medical precision, moving from resuscitation/stabilization to "damage control" surgery with alacrity.

Thus stabilized, the simulated patient was then moved to a temporary ICU set up on the aft mess deck. Again, the medical care rendered was flawless. The lessons learned from adapting spaces not usually dedicated to emergency surgery will be great value to both our navies.

The exercise was by any definition a huge success, and I proudly posed for an after-action photo with this superb medical team.

We then boarded a RHIB (Rigid Hulled Inflatable Boat) for a rapid sea transfer to another frigate, RSS Tenacious, for the voyage back to Singapore's Changi Naval Base.

From there a taxi brought me back to my hotel, where I entered my room at 0130 this morning. I was pretty tired after a long and action packed day, but grateful not only for the opportunity to be part of cutting edge operational medicine exercise, but also grateful for time spent with my warm and very engaging RSN friends.

And friendship, ladies and gentlemen, is what this job is all about.

Fujisan – Night Demons and the Right Stuff

Demons in the night.


We all have them. Some we know pretty well. Others exist only on the periphery of our consciousness as dark, disturbing shadows threatening our spirit and sometimes throwing us off purpose.


Spiritual writers refer to a "Dark Night of the Soul," which is a uniquely personal confrontation with those internal demons. To be clear, this post is not about organized religion or faith. Rather, I address a fundamental reality of our humanity. We all have a psyche, a term derived from the Greek for "soul" or "spirit. We all live a psychological or spiritual existence. Our psyche is where those demons play. It's where the "Dark Night" is said to occur.


One observer describes the Dark Night as "a time of powerfully intense internal struggling and questioning of purpose. This usually occurs just before a spiritual awakening. It is facing your demons, so to speak, and the abyss threatens to swallow you whole. If successful, the process strips away most of the ego that holds you back from seeing yourself as a pure being, distinct from yet inextricably connected to those around you and the universe as a whole."

Each of us who made the trek up Mt. Fuji eventually reached that point of "powerfully intense internal struggling and questioning of purpose." We all wanted to quit before we reached the top. We all had to reach deep inside ourselves to find some spiritual toughness that willed us on to complete the journey. We experienced a singular, personal relationship with that huge pile of volcanic rock. It became a demon to be confronted and conquered, a true dark night of the soul. "I will not let this f…ing mountain beat me." We each said it. When we each prevailed in the end, we had learned something new about ourselves. We accomplished a difficult goal in spite of every fiber of our physical and mental being screaming, "STOP!"

Many Japanese climb Mt. Fuji as a spiritual journey. We passed this woman, a septuagenarian if not older, trudging up the mountain alone. We passed her again as we descended, near the top, breathing labored with each slow painful step up those rocks. Hers was not a fitness jaunt. Her journey was clearly spiritual and personal. Judging from the age of her climbing stick, this was not her first trek. Darkness would fall by the time she reached the top. But such was her rugged determination, that no one could doubt she would reach the summit.

We all face challenges in life, sometimes by choice sometimes not. In the film, "The Right Stuff," Chuck Yaeger yearns to fly his experimental jet aircraft higher than anyone has ever gone before, "to find out where that demon lives."

When we take on difficult challenges we confront our demons. Demons not so challenged eventually run wild and take charge. Life then becomes either chaotic or sorely depressed. Only when we courageously confront those haunting demons do we truly learn who we are, "a pure being, distinct from yet inextricably connected to those around you and the universe as a whole," and that each of us in our own unique way really has the Right Stuff.

Fujisan: Gambatte Kudasai!

From a purely physical perspective, the climb up Mt. Fuji does not pose overwhelming difficulty. My boss, a marathon runner who climbed Fujisan in some sort of record time (3 hours), describes it as "more difficult than a half marathon." Indeed, the total round trip distance for the trek is just under 14 kilometers, which is only 8.7 miles. That's considerably less than a half marathon, and not even close to a full marathon. So surely anyone with a modicum of physical fitness can make that hike. Well, there is that 6000 foot altitude change and the relative hypoxia. That makes it more difficult, but still not insurmountable.

Nevertheless, most people find this outdoor adventure quite daunting. Why is that?


Just like a Jedi master, Fujisan plays mind tricks. You think you are close to the top, when you are not. You think the terrain is a gradual incline when it's really quite steep. You think you've gone an hour since your last break, but it's only been ten minutes. Or you think you've been climbing for only ten minutes and then realize its' been an hour.  Approaching the top, you seem to never get closer no matter how many labored steps upward you take. On the descent your mind sees the level terrain constantly receding, no matter how far down you go. You can even tend to believe you'll never ever get off that mountain at all.

Climbing Mt. Fuji presents more of a mental than physical challenge. No matter your level of physical fitness, you have to be smart and mentally tough to complete it. That means planning ahead to bring the right clothing, supplies, food, and water; but not to weigh yourself down with excess. You must know the route, and have a plan well thought out. What's the weather forecast? What if it's dark before you get back to 5th station? Might be a good idea to have a light source. It's a lot like flight planning. A good, thorough plan improves the probability of a successful and more enjoyable flight. 

On the other hand, you could not plan at all, like the Australian couple whom we encountered beginning their ascent just at dusk, with no light, wearing only shorts and tee shirts, and Keds vice hiking shoes. They admitted a spontaneous decision to just start climbing on the spur of the moment. Perhaps they also succeeded. Perhaps they have a different brand of mental toughness.


A welcome result of the mental challenges, climbing Mt. Fuji becomes a social event as well. The other climbers know what you're experiencing, especially if they encounter you going up as they descend. You build a camaraderie with your fellow stalwarts, often repeating the same mantra-like conversation: 


"Konnichiwa." 

"Gambatte kudasai!" 

"Arigatou gozaimasu."

Gambatte kudasai, means something like "Good luck," "Don't give up", "Hang in there," or most fundamentally, "Try your best!" I heard the same phrase often during the Tokyo Marathon, and it very nicely reflects the Japanese perspective on events that require mental toughness to complete. The Japanese believe that the effort is more important than the result.

So we did not finish the round trip to the Mt. Fuji summit in record time, or even in the time we planned. But we did finish it, and because we thought ahead we did have light for the final half of the descent after nightfall. We not only completed the physical challenge, but won the mental battle as well. The satisfaction of completing the effort overshadowed the actual result.


So as we descended we could rightly proclaim to new climbers who planned their trek in the dark to reach the summit at sunrise, "Gambatte kudasai!" 

For Bob

By now anyone who has ears with which to hear or eyes with which to read knows that Bob Goodwin was a model naval officer, a stellar emergency physician, an enviable family man, and an exceptional human being. His untimely death represents a tragedy of a magnitude that defies mere human ken. Today as he is laid to rest, we all mourn the loss of him in our own way, and for our own reasons.


I had so looked forward to welcoming Bob aboard the 7^th Fleet Flagship. 


I will miss working and collaborating with him as a fellow operational physician supporting our nation's forward deployed mission. Kathy and I both will miss Bob's and Bridget's friendship. We were eager to once again enjoy the Japan experience with their young family. We will miss sharing a part of their lives, and we will surely regret not watching Christopher and Paul grow up.


But Bob's life means so much more than the collegial friendship that this fellow naval officer and spouse will miss. I cannot begin to fathom what Bob's wife and children are feeling today. Our hearts and prayers reach out to them. No words in any language suffice to express our emotions and thoughts as we vainly try to conjure up some sense in all this grief.


Considering all the lives that Bob touched, his patients, co-workers, students, friends, and family, we should stand in awe of this one man's tremendous impact on humanity. His was an exemplary life of service and love, truly a life to celebrate, even in death. 


The Navy describes itself as "a global force for good." Bob was truly such a force. We are fortunate to have had him with us, however temporarily.


So even as we mourn the loss of that good force that was Bob Goodwin, we also optimistically anticipate his continued impact after death. Perhaps he was taken from fellow mortals early in life so that his soul could be released to an even higher calling. And perhaps we who grieve his loss still have him in our lives, only in a different and more enduring way. Perhaps he has "slipped the surly bonds of earth" to protect his beloved family and honored friends and nation in a fashion that a mere human cannot do. In that we must believe, and for that blessing we must be grateful. Thus we have hope, and in that hope we can truly celebrate his life.


I'm a better man for having known you, Bob. Fair winds and following seas, Shipmate.

Fujisan: Ask a Fool

If you want expert advice on climbing Mt. Fuji in Japan, just ask a fool.

Many Japanese avow that only a fool would climb Mt. Fuji more than once. But only such a fool would accumulate sufficiently diverse experience to qualify as an expert on the hallowed mountain. The mountain is replete with variables. Just the climactic changes alone might create an entirely unique experience from one day to the next.

Nevertheless, if you talk to enough people who've made the ascent only once, you will discern some common  wisdom on which you can confidently rely: 1) Start out adequately rested, 2) You can't put on too much sunscreen, 3) It will be cold near the top, 4) Wear good, comfortable hiking boots, 5) Bring plenty of food and water...or money if you plan to purchase same on the mountain, 6) The descent is harder than the ascent, 7) By the end of the day you will completely despise rocks.

Likewise, there are some consistent facts: 1) The linear distance from the 5th station to the summit is about 6.8 kilometers, 2) The elevation change is about 6500 feet. 3) The elevation at the summit is about 12,220 feet Mean Sea Level. Those were the numbers registered by my Garmin Forerunner GPS when we made the climb from Kawaguchiko's 5th Station. The other starting points may be slightly different.

I garnered some other pearls of wisdom from friends and shipmates who had previously completed the adventure: 1) The average time to ascend to the summit is about six hours. The descent usually takes half the time as the climb up. 2) Expect to be very, very tired at the end of the day. Not a good idea to drive back to anywhere in that state of fatigue. 3) Even better idea is to stay someplace close the night before, and also the night after the climb. 4) Bring a headlamp or flashlight in case you end up finishing in the dark.

These aphorisms all proved to be mostly true. Our ascent took seven hours. It did get a bit cold at the top, but not bad at all. The descent, for the less agile older guy anyway, took five hours. We finished in the dark, thankful for the illumination we brought with us. We did not bring enough food or water, but we survived. One of us (aforementioned older guy) could benefit from caloric deficit in any event. And yes, we were too tired to go anywhere but to our ryokan at the end of the day. Birru and onsen worked very well to assuaged the kinks and stiffness of a day's hard mountaineering.

That's pretty much the physical gouge on climbing Mt. Fuji. Pretty straightforward, really. But this Bucket List adventure is not just about the physical challenge. Hey, we have marathons and triathlons for that purpose. The Mt. Fuji ascent is much more of a mental and spiritual test. More on that in later posts.

One final word of wisdom from the older guy: Trim your toenails before you go. As a runner I should have known that.

Fujisan: Prelude

Before:

After:

Well, not really fully after, since our intrepid mountaineers would still have to descend the mountain, with darkness rapidly approaching. That would prove much tougher than expected.


The true story, of course, happens between the bottom and the top. Therein reside some cherished moments and memorable encounters. This story needs telling as a life event, not a travelogue. But even so, it describes only one climb at one point in time. It is therefore neither saga nor guidebook. Rather, we will attempt to convey the deeper meaning of the feat, to explain how the summit celebration bespeaks not of technical prowess or expertise, but of each individual's very personal victory over self. That victory is at once not only physical, but mental and spiritual as well. Thus the climb of Mt. Fuji becomes a singular life event worthy of "Bucket List" status.

So, if you want expert advice on climbing Mt. Fuji, just ask a fool.


(To be continued...)

Converted

Okay, so maybe I was misguided (to borrow a Presidential term) in my April diatribe against the new Navy working uniform (NWU), colloquially know as "aquaflage." I certainly believe that a good leader should readily admit mistakes, so here goes (gulp, deep breath): 


I. Was. Wrong. 


There, I said it. Wasn't so hard, really, and felt pretty good. Why do some politicians find honesty so difficult?


At any rate, there I was, fully intending to hold out against buying the new duds for the remainder of my operational tour, and to wear instead my venerable wash khakis and coveted flight suit. Then I learned that the new NWU is the prescribed uniform for our upcoming humanitarian civic assistance visit to Palau. Well, it's one thing to be a non-conformist on board with fellow shipmates. It's quite another to be out of uniform when representing the U.S. Navy whilst providing needed medical care to an external population. We do call it a uniform for a reason.


So I reluctantly put aside my traditionalism to traipse over to the uniform shop and purchase one set of the new NWUs. This included rank and warfare devices to be sewn on by the NEX tailor, at an additional price of course. Still, I kept the cost below $200 by not buying the very expensive regulation parka and liner, since I doubt it will be cold in Palau. And I was delighted to learn that I can wear my 18-year old comfy leather flight boots instead of purchasing the newly prescribed leather boot. 


On the first of July I debuted my new flage uniform. Hmmm. Fits pretty good, even right off the rack. Feels like pajamas, and no need to tuck the shirt into that non-existent virtual space between waistband and belly. This may not be khaki, but I sure don't miss that cincture-tightening sensation as the day progresses. What's that you say? No ironing required? Now that's very nice. And all these pockets for stuff. I gotta admit, it's a lot more comfortable and convenient than what I've been wearing. Still, it's not khaki...


In the morning I felt a little self-conscious with the new look, but by the end of the day had completely converted to that uniform. I fully understand now why our sailors like it. It's comfortable, very forgiving of an average physique, and does not require a lot of care and maintenance; thus allowing them to devote their time and energy to the jobs at hand instead of the ironing board and mirror. It is, indeed, a very practical improvement over the panoply of uniforms currently sported aboard our ships.


The final conversion came with the compliments from colleagues who have nothing to gain by flattering me. I never heard this so many times in one day while wearing any khaki Navy uniform: "Hey, Doc, that looks really good on you." 


Sold!