Life in the armpit of nowhere

After four months of living together, working together, sleeping in the classroom together, sleeping in armoured personnel carriers together, and playing on iPhones together, our group has finally split. As you’ve seen from the previous blog entries, it hasn’t always been easy. Sometimes, in fact, it’s been really difficult. Coping with a high pace of learning in a foreign language with people in the top 0.5% of the population in terms of IQ (a pre-requisite for them getting scholarships for medical school from the army), while not getting enough sleep, and living next to the Georgian soldier whose personal hygiene and eating habits are possibly the cause of most new species of bacteria discovered in the past century, has not always been an enjoyable experience. 18 hours days followed by a weekend poring over reams of small-print Hebrew medical and military literature has at the very least been as difficult as University, and probably more so with my old and tired brain.

Getting to the end of the course was certainly not a sad moment. Of course, it was tough to say goodbye to the people who had effectively been my friends and family for the past four months, but as we expect to see each other at various conferences, mass casualty incidents, and wars, it was more of a ‘lehitraot’ (see you soon), than a ‘shalom’ (goodbye).

Graduation

The end of the course arrived and we celebrated with a fancy graduation ceremony. Family, friends, the surgeon general of the army, various commanders, and all the ecstatic people who we would shortly be replacing, came to celebrate the end of our training.

The IDF, like most militaries in the world, holds discipline and efficiency in high regard. Unlike most militaries in the world, the IDF tends not to actually do very much to encourage either. On the one hand, it makes sense that we spend our time learning military skills and medicine, rather than learning how to march in perfect unison. On the other hand, when a number of soldiers (including several seemingly dyspraxic ones) march for the first time in their lives 24 hours before their graduation ceremony (pretty much the only time 99% of soldiers will ever actually march anywhere), it’s inevitable that the outcome will not be impressive.

With hundreds of guests lining the yard (including Deborah, my cousins Beryl, Pinchas and Dina, and Deborah’s auntie Paula), we took to the march, in time to a very nice recording of some generic military marching music presumably recorded some decades ago when the IDF still used military orchestras. In true Dad’s Army style, we set off – some on the left, some on the right – some hopping on one leg until they could figure out which one everyone else was using. Having received our new berets just a short time before the course (in my case about three minutes before – each battalion has its own colour scheme, and therefore each doctor had to arrange somehow for someone to deliver the appropriate uniform in time for the ceremony), most had their beret leaning to the right, one or two to the left. Some were completely devoid of rhythm finishing one step behind everyone else. But, it looked okay in the pictures, and ultimately, unison marching simply wasn’t the point of our course.

So, after some considerable time standing in the Israeli summer sun in full uniform, with a thick wool cap on my head, listening to various speeches and pep-talks about how great we all are, (why they didn’t just say dulce et decorum est, I do not know), we patronised the audience with some formation marching creating words like ‘Thanks’, ‘IDF’, ‘Medical Officer’, and finishing with a somewhat deformed Star of David, before throwing our berets in the air in cheesy American-college-graduation-style fashion.

With that, our course was complete, and Deborah and I departed on a week of compulsory holiday (where the army forces you to take leave at a moment convenient for them, so that you won’t ask to take it at a later date that doesn’t suit them entirely). In a remarkably small time, we managed to pack in a lot of fun – hiking in the Galilee, camping in the Golan Heights, white water rafting on the Hatzbani, eating in posh restaurants on the riverside, picking avocados on the roadside, swimming in the sea of Galillee and a bit of compulsory DIY in the few remaining days.

Up until a few days before the end of the course, none of us knew where we would be based for the next 14 months. Many of us wanted to head to infantry units, where we would be isolated, involved in the management of military operations, logistics, hygiene on base, wartime preparations, and once in a while a little bit of medicine. Many wanted an easy life where they could work 9-5 in a cushy clinic near mummy and daddy. Some wanted a nice in-between, and that is precisely what I went for and what I supposedly got. I was proud to be appointed the doctor of ‘Kfir’ training base, the home of one of the IDF’s anti-terrorism battalions, and as such, will spend the next year of my life with the hundreds of soldiers starting out on the course of a fighter.

Arriving to the base for the first time was in itself an experience. Based very, very deep in the West Bank, I was expecting a veritable fortress surrounded by enemy eyes – and was amazed to see that the reality was very different indeed. As my bus wound its way through the hills of the Judea, starting in Jerusalem and heading North East, I realised just how utterly desolate the West Bank is – with the exception of a few clusters of tents of the resident Bedouin population, still living without electricity (except the occasional generator), and a handful of green Israeli settlements, there really is nothing here. In fact, I’m writing this while on the bus home, and right now I’m stopped at an army base on a hill top – I can see miles in every direction, and there is simply nothing here. No roads, no infrastructure, no villages, nothing except barren yellow hills; just as the whole region was before the pioneers of the 19^th and 20^th centuries created Israel.

Eventually, we arrived at the base, surrounded on all sides by hills, with no sign of human habitation outside of the base except our over-ground water pipe, serving the base with 50 degree water throughout the day, and a suspiciously placed Bedouin tent-village, conveniently in easy reach of said water pipe.

By coincidence, my first day on the base, was also the first day of most of the new influx of recruits, who were arriving throughout the morning. As I entered the base, I saw a mix of excitement (in the 1% of the population who had dreamed of this day since childhood), and sheer panic and depression (among the 99% of the recruits who hadn’t yet left childhood). Hundreds of children in green uniform roamed the base before me, not knowing where they were meant to be, many away from home for the first time in their lives, some scared to use the toilets or drink the hot water, many on the verge of tears because the phone signal in our valley is too poor to check Facebook some of the time. As I tried to find my clinic, weaving through the kids, the excruciating heat bringing tears to my eyes, I realised that my placement may not be as straightforward as I had anticipated.

I had had some very noble plans for my arrival at the base. I even made a list of things to do and when.
- Face to face meeting with each medic – get to know them, explain my ideas for the efficient management of the clinic and hear their concerns
- Tour of the base – learn where things are, useful contacts, emergency protocols, evacuation routes
- Tour of the area – learn where our neighbours are, where our enemies are, what danger spots are present
- Meet the commander of the base and talk through my role
- Face to face meeting with the doctor from the sister base a few kilometres away (more on that in due course)
- Face to face meeting with the commander of each platoon to make introductions.

As the saying goes, the best laid schemes yada yada. Within 4 hours of my arrival, I had abandoned all hope of complete most of my goals, at least in the near future. Instead, I was sitting at a desk seeing my first patients, working with a computer program which would be infuriating at the best of times, even more so due to the fact that when we had had our training session on how to use this program, there had been a catastrophic failure of the entire computer network. Trying to differentiate between patients, I could categorise them into the following:

- Panic attack
- Fake panic attack
- Fake medical condition (doesn’t want to be here, ‘Motivation Zero’)
- Fake medical condition (wants to be here, mummy doesn’t want him to be here, instructed him to write ‘Rare Bowel Disorder’ on his medical declaration)
- Joint pain which bizarrely started after a 40km hike with a 30kg back pack
- Serious medical condition (that absolutely should not have made it to an elite fighting unit, but somehow managed to slip through a hole in the net big enough that a dead terrorist with one leg would get through)

Throughout each day, the timetable is fairly standard – I see routine cases in a supposedly organised fashion from 0830 until 1800. Of course, at the same time, I’m permanently on stand-by for emergencies; so many times have I been in the middle of dealing with a patient with, for example, diarrhoea, when the alert comes in for a suspected heat stroke. Everything stops, I run to the emergency room (which is literally that, not a big fancy department, but another little room in a little caravan, with a bed and a few drugs in it... and the obligatory rectal thermometer – both a diagnostic tool and a preventative measure against soldiers faking heat stroke – and we wait for the soldier to be carried in on a stretcher by another four soldiers who have just run across the baking desert to bring him to me. Many times have I wondered how many soldiers suffer from heat stroke as a result of running to bring in a soldier suffering from heat stroke.

Inevitably, every day, my clinics run late because of cases like this. So I’m lucky to finish my clinical day before 2000. Then of course, I start the paper work, blood result processing, letter writing, follow up of difficult cases, and so on – all in Hebrew, and all on a fantastically slow computer running an intricate and temperamental computer program. Needless to say, the emergencies carry on throughout the night and as I also cover the region’s roads (our ambulance is the only emergency vehicle permanently on standby in the region), there are plenty of urgent things to do. This week saw a lorry fall off the road, three scorpion stings (including two, yes two, to soldiers’ heads – learning to sleep in the desert isn’t instinctive), anaphylaxis after a hornet sting, and a school bus of children that had rolled over. The anaphylaxis and the school bus were in fact false alarms (because people are stupid), but nonetheless resulted in all the stress and panic of emergency situations until proven otherwise. So, all in all I’m lucky to work less than an 18 hour day.

As the weeks have passed, many of the most problematic soldiers have been excreted from the base, to my immense joy. The logic of keeping a soldier who doesn’t want to be here defies me – the odds of such a person developing into a champion of the battlefield are slim to nil, and through his 8 months as my patient, he is likely to return time and again with aches and pains, various complaints, requests for referrals – anything he can think of to get out of our baking-hot caravan park in the middle of nowhere. So slowly but surely, the work load seems to be slowing. Most nights are undisturbed, and having learned which of my medics are fantastic and which ones are utterly inept, I can now filter the ‘emergency’ phone calls at 3am, knowing when to trust the medic and run, or when to grill the medic with a list of questions to whittle down the diagnosis from ‘massive arterial haemorrhage’ to ‘cut finger on piece of paper’.

I’m not alone on the base, although it often feels like it. Technically, there are four ‘senior treaters’ between two big bases – one paramedic, and three doctors. Paramedics are a fairly new investment in the army – people (usually women) who are trained up to be fully qualified paramedics in a relatively short time, in exchange for selling their souls to the army (much like the apprentice doctors who learned medicine for free in exchange for working like a dog without a salary for the next several years). The paramedic is there as an emergency on call resource – either when there is more than one emergency simultaneously, or when I’m not around for another reason. The problem is she also covers the other base, and various training exercises in the region. So, it’s rare she’s actually here, and even rarer that I or my medics know she’s around – and therefore the work still falls on me. In addition there’s technically a second doctor here – the commander of the clinic – a women who outranks me and can order me around, and who is leaving in 2 months. As a result, she seems to treat a remarkably small number of people, doesn’t split up the ‘days off’ evenly between us, but like most bosses, seems willing to take credit for anything good that happens under her authority. The big question is who will come to replace her? A good hard-working doctor who believes that work should be split evenly would effectively half my workload, but only time will tell.

Of course, the hardest aspect of the entire experience is the lack of time I get to spend with Deborah, who continues with her editing work. It’s a great job in terms of its flexibility (working from home and choosing her own hours and to an extent the amount of work she takes on), but results in day after day home alone. Soon, Debs will start working as a pharmacist in Shaarei Tzedek, one of the best hospitals in the country, and so we are both looking forward to her getting back into her vocation. But in the meantime, she continues to write and edit Q&As on obscure medical topics, such as ‘What is the best type of shoe for someone with Crohn’s disease to wear’ or ‘How many times a day should someone with eczema need to take a pee’. The work is divided up among a few editors in Israel, supervised by a regional manager, and super-supervised by a big-wig manager in the USA. At the same time, another office in the Far East does similar work for far less money, but with far more heinous errors in the English. So a stressful competition has developed between the two centres, each trying to achieve better results in less time and with no guarantees of long-term job security. As far as I’m concerned, Debs should sit back and enjoy the ride, in the knowledge that she has a pharmacy job just around corner (covering maternity leave for someone who should be due to pop in a few weeks), but being the good conscientious worker that she is, and keeping in mind the possibility that she may work two simultaneous jobs (neither being full time), she’s getting sufficiently stressed to keep our blood pressures up.

As my only time to write the blog is now during bus journeys, I must sign off now – no more battery. But there’s a lot more to tell – hopefully in the next installment...