The Peace Widow

The Peace Widow

Recently I saw one of my regular patients. She was a smart lady in her early-forties. She was telling me that she has a lot of fun on the weekends when she looks after her one year old grandson. She told me that her husband has to fend for himself when she is busy with her grandson. I replied that he should not mind as it is his grandson too. He does not mind, she said, but he is technically the step grandfather. The grandson was from her son from her first husband.

Does your ex-husband get to spend time with his grandson too, I asked? She was quiet for a while, then said “no, he is dead”. I was taken aback, and said that I was very sorry to hear that and asked “when did he die”?

He was killed in Northern Iraq in 1994 she replied. I thought for a minute, then asked “but the first Iraq war ended in 1991, how was he killed in 1994. She then told me the story of the “Black Hawk Shoot Down” incident.

The 1994 Black Hawk Incident was a friendly fire incident over northern Iraq that occurred on 14 April 1994 during Operation Provide Comfort. This was an attempt to establish a no-fly zone over Northern Iraq. The United States Air Force was trying to protect Kurdish civilians from Saddam Hussein’s Air Force. 

The pilots of two United States Air Force F-15 fighter aircraft operating under the control of an airborne warning and control system (AWACS) aircraft, misidentified two United States Army Black Hawk helicopters as Iraqi Mi-24 "Hind" helicopters. The F-15 pilots fired on and destroyed both helicopters, killing all 26 military and civilians aboard, including personnel from the United States, United Kingdom, France, Turkey, and the Kurdish community.

My patient’s husband was 22 years old and was in one of those helicopters. He was one of those 26 people that were killed. Apparently, the AWACS operator had been told of the presence of the two friendly helicopters, but he failed to make a note this. Subsequently, when the F-15 pilots requested the AWACS for identification of these helicopters, they were unable to do so. The F-15 pilots were required to fly close by to see the helicopters visually. They misidentified them as Iraqi, despite two large American flags painted on each side of the Black Hawks.

The only person ever court martialed for this incident was the AWACS operator, and he was not punished. My patient became a very young widow with a new born baby son. The Army later gave my patient videos of the whole shoot down incident. The rear helicopter was shot down first. Her husband was in the lead helicopter and she saw it take evasive action to avoid being shot down, but the missile still hit it. She saw it go down in flames with her husband inside.

My patient was devastated after this. The Army gave her full benefits as a widow of a soldier killed in action, but no other compensation. The families of the foreigners killed in this incident were given $100,000 each as compensation by the United States department of defense.

My patient devoted her life to bringing up her son. She said that there were many men who expressed an interest in her, but she turned them all down. Her son grew up and got married and had a son of his own. This was the grandson that my patient was spending her weekends with.

Twenty years after she became a widow, my patient was in her forties. She then met a wonderful man. He had the same first name as her deceased husband. She fell in love and finally decided to get married. As soon as she got married, the military took away all her widow benefits. She is however content with her life today.

While I was happy that my patient had finally been able to move on with her life, I felt sad as to the circumstances of her becoming a widow. Even though her husband was killed in action, there was no war going at that time. He was also killed by his own side, in a ‘friendly fire’ incident. Most inappropriate to call it that because there is nothing ‘friendly’ about being fired on, no matter by whom.

Women who lose their husbands in war are often called ‘war widows’. In my patient’s case I felt it more appropriate to call her a “peace widow”. However, she is now no longer a widow, and I hope she continues to do well and finds ever more peace and happiness.

                                      The remains of the 26 victims of the Black Hawk 

                                      shootdown arrive at the U.S. Army Mortuary Center.

The Surgeon

The Surgeon

A memory of William Dayton Shelly, 2/17/43 to 4/13/08

Recently hurricane Matthew came through North Carolina. It caused widespread flooding and destruction. Many roads and bridges were destroyed. Homes were flooded and there were widespread power outages. Several lives were also lost. I was lucky. I lost power for only three hours, and was not personally affected. I however saw the devastating effects of this hurricane around me. This led me to remember another hurricane many years ago and a remarkable physician.

It was September 1999. I was working as an Internal Medicine physician in a small hospital in Eastern North Carolina. Hurricane Dennis had just passed through, causing a lot of rain, but no significant damage. The ground was however waterlogged, and we heard of another hurricane forming in the Atlantic. This was named Hurricane Floyd. I was not too worried. It was categorized as a category 2 and that did not seem too bad.

On September 16th, 1999, Hurricane Floyd made landfall in North Carolina. I lost power in my home that night as the winds howled around me. A large pine tree in my yard fell, but it fell away from the house. In the morning my home was intact and I still had running water. My neighbors came by and helped me clear the fallen tree. The power came back on later that afternoon and I thought the worst was over. I was wrong.

The ground was waterlogged from Hurricane Dennis when Floyd came onshore. The rains caused widespread flooding and nearly every river basin in the eastern part of the state exceeded 500-year flood levels. In total, Floyd was responsible for 57 fatalities and $6.9 billion dollars ($9.8 billion in today's dollars) in damages. Due to the destruction, the World Meteorological Association retired the name Floyd.

My office was closed because of the storm, but the next day was a Friday and I was on call for the weekend. I got a call mid-morning about a patient that had been brought in and needed to be admitted.

It was a sunny day as I drove to the hospital. I knew from the news that many surrounding areas had flooded. Waters had continued to rise as many streams and rivers overflowed their banks. I also knew that the National Guard had been called in. I was however unprepared for the scene that greeted me as I got to the hospital.

A large and very loud Chinook helicopter was landing in front of the hospital. It was bringing people evacuated from the floods. They were supposed to be taken to shelters from there, but many dazed people were walking aimlessly around. There were also many National guardsmen in their Army uniforms. It felt surreal, almost like a scene from a war.

I went in to see my patient. She was an elderly lady in congestive heart failure. Her heart rate was 30, which is very low. She was in a medical condition called a heart block. She needed a pacemaker. We put pacer pads on her chest and started to electronically pace her heart. Unfortunately, this was only a temporary measure. I had to get her to a Cardiologist so that a more proper pacemaker could be placed. This meant getting her transferred to our local teaching hospital.

I called our nearby teaching hospital and explained the problem. The operator told me they were on diversion and transferred my call to the chief of staff. I knew the chief of staff, and he told me that he would love to help, but they had lost power and running water. Their generators were running, but the flood waters were rising and those generators were about to be flooded. He said he would be happy to try to get her transferred once things got more stable.

With dismay, I realized that I was probably on my own for now. Luckily our patient was stable. I was however worried as I walked out of the hospital. Sitting outside the hospital was our surgeon. He had moved a few years ago from a practice in Pennsylvania to our small hospital. His motto was "love what you do so much that you never have to work a day in your life". He was sitting outside because he was smoking. He used to smoke fancy brown ‘More’ cigarettes. What is the matter, he asked?

I told him about the situation with my patient. He said, oh I can put trans-venous pacer wires in. This involves putting wires through a central line into the heart. I would have to go into the operating room with him and use the cardiac monitors to assess if the leads were placed in the right place and working properly. This is only done by Cardiologists today, but our surgeon said he had done this many times before. 

So for the first (and last) time since 1993, I put on scrubs and went into an operating room. He put the leads in through a central line into the heart, and I used the cardiac monitor to guide him. The pacer started working immediately and the patient’s heart rate improved. Her symptoms also improved later that evening. The next day, we were able to transfer her to another teaching hospital in a stable condition. That day my respect for our surgeon increased significantly

As hurricane Matthew came through, I thought about hurricane Floyd so many years ago and our remarkable surgeon. He has since passed on, but I will never forget his skills on that day, and I try to follow his motto of loving what you do so much, you never have to work a day in your life.

                                                   Effects of Hurricane Matthew

Syndrome de Munchausen

Syndrome de Munchausen

In my many years as a physician, I have seen many unusual cases. Some of these have been very difficult to diagnose or treat. Some of the most challenging ones have been those thought to have the Munchausen’s syndrome. I say ‘thought to have’, because this is a difficult diagnosis to confirm.

I remember one patient who was a man admitted with an infection in his blood. He was in his 50’s with no major medical problems. I was in my fellowship training in Infectious Disease at that time. We were called to see him in Consultation, because the bacteria growing in his blood was very unusual.

He had no risk factors for developing a blood infection. I took a detailed history on him and we could not find a reason for the bacteria to get into his blood.  While the bacteria was unusual, it was fairly sensitive to antibiotics. We treated him with intravenous antibiotics and the infection resolved and he was discharged.

A few months later, I was back on service, and we were consulted on the same patient. He had developed another infection of the blood. This was a different bacterium, but also very rare and unusual. We did a detailed work up on him, including an exhaustive history, but could find no cause. He was treated with antibiotics and recovered and was discharged.

In the next several months, he was admitted two more times. Each time he had a blood infection, but with a different bacterium. He responded well to antibiotics. On his fourth admission, he told me that these repeated infections were making it difficult for him to work and he had applied for disability.

My attending physician sat down with me to re-evaluate this patient. He had no risk factors for repeated infections. The bacteria involved were very unusual, but also different each time. My attending asked me if I noticed anything in common with his repeated infections. The only thing I saw was that these were unusual infections from different bacteria that we rarely saw.

He then pointed out to me that all these bacteria can be found in stools. How would they get into his blood, I asked? His theory was that our patient was injecting himself with toilet water, in an attempt to get disability. But how are we going to confirm that, I asked? Let us ask him he replied.

We went back to our patient and asked him. He became very defensive and angry. He told us that if we do not have the ability to diagnose and treat him, then he prefers to be discharged. We did treat him with antibiotics and cleared the infection. He was discharged and was not seen again in our hospital. We were never able to confirm a cause of his repeated infections.

While we were not able to prove it, we thought that the above case was an example of Munchausen’s syndrome. This basically means a disorder imposed on one’s self. The incidence and the reasons for this are often not clear as patients will deny it when confronted. The presence of this condition usually points to a deeper underlying psychological condition or some kind of secondary gain.

Baron Von Munchausen was a fictional character created by a writer in Germany in the 1700’s. It was based on the real life exploits of Hieronymus Karl Friedrich von Munchhausen, a German nobleman in those days, who was famous for his tall tales.

Baron Von Munchausen riding a cannon ball.

Thus fabricating symptoms or imposing a condition on one’s self used to be called Munchausen’s syndrome (or Syndrome de Munchausen in French). The modern term for this condition is now ‘Factitious Disorder’, but the term Munchausen’s is still commonly used.

As for our patient, I do not know what happened to him. I hope he is doing well today.

The Amputator

The  Amputator

It was 1991. I was a newly minted doctor and was starting my residency in Trauma and Orthopedic Surgery in our local Teaching Hospital in the town of Zaria in Northern Nigeria.

I was one of two new residents who would share call. Accidents on the roads in Nigeria are common and many injured would be brought into our Emergency Room. I learnt to deal with many types of fractures and was also learning how to do Orthopedic Surgery.

It must have been my second time on call that I was called to see a young man. He had fallen off his bicycle and broken his leg. His family took him to the local bone setter, who splinted the leg with a splint made of wooden sticks. Unfortunately, these were tied on too tight, and the leg became gangrenous.

They went back to the bone setter, and he told them that they had displeased the gods and that is why his leg was rotting away. The desperate family then brought him to our hospital.

Even before I got to him, I could smell the strong sickly smell of rotting flesh. As I unwrapped the splints, I could see his leg had become gangrenous and would have to be amputated.

I broke the news to the patient and his family, and they were naturally upset. The patient then asked me to do what needed to be done. I called the operating room and the anesthetist. I had assisted in several amputations before, but this was the first I would do on my own.

He was wheeled into the operating room and the anesthetist put him to sleep. I was assisted by one of our surgical technicians. I prepared his leg with antiseptic solution, then draped the leg and began the amputation.

It is easy to do an amputation, but making sure that the patient has a good stump that will make using a prosthesis easy is however quite technical. I marked out the flaps and started cutting. I found the large blood vessels and tied them to prevent bleeding. A saw was used to cut the bone. Finally, the flaps were sutured closed.

The patient did well, and eventually he got a prosthesis that enabled him to ambulate well. I ended up getting these types of patients frequently and did regular amputations. I was so frequently in the operating room with an amputation, that one of the General Surgery residents (a close friend) decided to call me “The Amputator”. This was a play on the title of the 1984 Arnold Shwarznegger movie “The Terminator”. The name stuck, and from then on, many of my friends used this as my nickname.

One day, a three-year-old girl was brought in with gangrene of her leg. She had developed rickets, a disease caused by a dietary deficiency of vitamin D that is common in children in West Africa. This had led to bowing of her legs. She was an only child and her parents had waited many years before being able to have her. Her mother wanted her legs to be perfect and straight and decided to take her to a local bone setter.

He broke her legs and tied them straight with the wooden sticks. Unfortunately, one leg was tied too tightly and caused gangrene. The little girl was quiet and stoic when I examined her. However, when I broke the news to her mother that the leg would have to be amputated, she started wailing loudly as her husband tried to comfort her.

I proceeded to amputate the little girl’s leg. It was a very traumatic experience for me. That little girl’s quiet bravery affected me deeply. Amongst the many patients I often wonder about is this brave three-year-old, who should be a grown woman now. I hope she is doing well.

                                                Traditional Bone Setter Splint