The Wild West

In many ways this base resembles the Wild West just like the movies.
For one, there is spotty law enforcement (rules enforcement –with basically
everyone being armed there is no real law breaking). There seems to
be an "everything goes" mentality in some areas. Only slowly is some
conformity is being introduced. A few weeks ago everyone on base was
notified that license plates were being introduced on the base to
finally be able to track vehicles (aka non-tactical vehicles).
Currently there are no consistent means of identifying vehicles. Some
companies will have an 8.5"x11" piece of paper taped to the windshield
with some cryptic identifying information on it but most go without
any marks. The problem is compounded since we have a very limited
number of vehicle models on base and so many vehicles look the same.
The most prevalent vehicle is the international version of the Toyota
4-Runner which is known as the Hilux Surf here. With most
non-tactical vehicles being imported from Pakistan, the driving is on
the right side while the traffic flows on the right side. So there is
a setup for accidents or erratic driving and so the need for good
vehicle identification is understandable. There are basically 3 paved
roads here with all other routes being crushed gravel or impacted
dirt. Passing vehicles churn of large dust clouds making walking here
hazardous to your lungs. A road grid of sorts is in the works but
most signs are ignored and since there are no side-walks people and
vehicles come into frequent confrontation. There are also no street
lights. Currently a $5000 reward is out for information identifying
the driver in a hit-and-run that killed a soldier.
The 'wanted' posters are not the only other similarity to the Wild
West. The social center of the airfield is a collection of eateries
and shops collectively known as the boardwalk. The establishments are
arranged in a square with an internal 'quad' that contains a
basketball court, "fields" of packed dirt and rocks, and believe it or
not, a street hockey rink. The latter is a testament to the Canadian
presence. A covered wooden walkway around the inside gives the place
its name. The place is a melting pot for all of the NATO forces. I
can picture the swinging saloon doors. Crafty entrepreneurs have are literally working out of shipping containers along the board walk.
The fact that everyone is walking around with a weapon is another
similarity to the Wild West. The only thing missing is shootouts at
high noon.
Housing varies significantly as well. Some folks live in large tents. Other options include the 35 man-7 room dwellings that I live in, stacked container housing units, and for the select few, 2-story concrete dorms. The latter are being constructed for NATO troops. It is not uncommon to see them laying out on cots, sunbathing in Speedos. That sight is probably where my PTSD will come from, not rocket attacks.
To sum things up: the varying accomodations and the overall slow move towards rules, orderliness, and conformity must have been what the American West was like back in the late 19th century.
The picture is of a boat that is located on one of the lots on this DESERT base. Go Army.

A Combat Stress Control Psychiatrist's Thoughts on the Ft. Hood Shooting

The tragic shooting rampage at Ft. Hood last week has special significance to me as I too am a military psychiatrist. I deployed to Iraq for seven months in 2008 as a combat stress control psychiatrist (see picture)just as Major Hasan was scheduled to do. Major Hasan completed the military medical school (Uniformed School of Health Sciences) in Bethesda (4 years), then completed a residency at Bethesda/Walter Reed (4 years) and a fellowship in disaster psychiatry (2 years-ironic since he created a disaster), and practiced in Bethesda for several years before being transferred to Texas and finally being tasked to deploy. Of note, he incurred approximately nine years of mandatory payback service to the Army for all of his training. When it came time to start paying back the Army he caved.

The media coverage seems to have entertained every possible motive for the shooting including religious zealotry, posttraumatic stress disorder (PTSD) by proxy, domestic terrorism, and retaliation for having been discriminated against. Family members of the shooter have commented that he was 'mortified' about deploying to a combat zone. The given reasoning is that Major Nidal Hasan counseled so many PTSD patients that he had a distorted view of deployment and thought that his life would somehow be in constant danger. Having been deployed to a combat zone as a combat stress psychiatrist I can assure you that he would be in minimal danger. In fact he would most likely be in an office going routine patient care much like he has done back in garrison.

An even more absurd theory to me is that he developed PTSD "by proxy" from talking to his patients. That means that he now has PTSD from hearing about traumatic experiences rather than actually having been the victim of the trauma. That is akin to getting PTSD from watching a horror movie. A more likely experience from hearing frequent traumatic experiences is compassion fatigue. Compassion fatigue is basically losing empathy for your patient because you have heard similar stories or worse stories many times before or because you feel like your patient's are exaggerating symptoms/downplaying recovery for the sake of compensation. Regardless of whether he had PTSD or compassion fatigue, it does not follow that he would unload several magazines into co-workers.

It has also been noted that the shooter was extremely reluctant to deploy to a combat zone. In my opinion a military health care provider should be eager to practice in a combat zone because that is fundamentally what differentiates him from his civilian counterparts. In fact the field of medicine has been significantly shaped by war experience. For instance, emergency medicine as we know it was in large part developed from war time experiences, particularly Vietnam experiences. While I can imagine someone with children perhaps being reluctant to deploy, the shooter was by all accounts single and not a father. Again, reluctance to deploy does not translate to a shooting spree.

Why then did he shoot into a crowd that included his co-workers? We may have to wait for the trial to find out, but what is certain is that if he had not had access to high performance firearms. Could the tragedy at Ft. Hood have been avoided if guns were not accessible to the general public? How much damage would an impulsive, angry man been able to do if he did not have high performance weapons and ammunition on hand? Gun rights advocates would tend to gloss over the fact that the shooter had a weapon and instead point out that the shooting spree may have been aborted earlier had more people in the crowd been carrying weapons. No comment.

In the end the shooter's legal defense seems to be aided by the media in that they are proffering so many potential motives/defenses for his behavior. I think he is likely mentally ill -schizophrenic, and that his symptoms made him very susceptible to extremist propaganda that ultimately led him to shoot innocent Americans. Time will tell.

One Month Down

I have reached the one-month mark of my deployment! Four more to go. Deployed personnel manage the duration of their tours in many ways. . Some scratch off one day at a time. Some count week by week. Others will only start counting after they reach "Over the Hump Day," i.e. the half way point of deployment. Some elaborate "countdown timers" are in use over here. Some timers are simple spreadsheets that count backwards and give you percentages of time remaining and time elapsed. Others are more sophisticated and can feature an image (PG-13 of course) that is gradually revealed in proportion to the elapsed time on deployment.

The one month mark is a special milestone. First, you are eligible for the deployment/campaign ribbon once you have reached the one-month mark in country. In my case that makes the Afghanistan Campaign Ribbon/Medal. While relatively exotic over the first few years of the conflict, this ribbon is becoming more common place in US military service members. In contrast the Iraq campaign ribbon is almost ubiquitous among Army service members who served within the past six years. Since this is a NATO conflict, troops who serve in Afghanistan also earn the NATO ribbon/medal after 30 days in country. The military also starts paying 'Family Separation Allowance' of $250.00 to service members who have been deployed for more than 30 days. I have no idea how that amount was determined. I should deposit the $250 each month for future therapy sessions for my kids for not having their father around for five months or to compensate my wife for having to be a single parent to three kids.

I remain amazed at what people will do for a piece of colored fabric i.e. a ribbon. This human propensity is apparently taken advantage of starting at the Cub Scout/Brownie level in the United States. In discussions with service members in my capacity as a psychiatrist I frequently explored fantasies of earning a Purple Heart because of the prestige of it and how rare the ribbon is. Unfortunately there exists a disparity in how readily awards/medals are awarded between the varying services. The Army is the most liberal is issuing medals and the Marine Corps in notoriously stingy. In my tour in Iraq last year it was commonplace for all unit commanders and senior leadership to earn a Bronze Star apparently for simply doing their job for 12-15 months. I suppose the ease of which medals are issued is an attempt to shore up morale that is flagging due to the prolonged nature of the war and the demoralizing effect of guerilla tactics.

One 'benefit' of the two wars we have been fighting since 2001 is that our military has more actual combat seasoned troops than it has had since WWII. If even a fraction of these service members remain in the service for their entire careers and assume leadership positions then I believe that future military decision will be made with a significantly higher degree of practical expertise than say decisions during the 80s, 90s, and first few years of the 21^st century. In the line community the likelihood of completing a career without a combat zone deployment is becoming a rarity. In the physician community certain specialties are being deployed more than others. Mental health providers may well be the most deployed while deployment remains a very rare occurrence for uniformed pediatricians and obstetricians. In fact deployment including sea tours remains so rare for the latter two specialties that the question has been raised why we need uniformed pediatricians and obstetricians/gynecologists at all. Civilian providers could easily provide those services on the mainland and even large overseas bases.