Dr. Hasan’s motivations, explained by the New York Times

President Obama expressed confusion as to why Dr. Nidal Malik Hasan shot and killed a group of American soldiers. Perhaps that is because he was reading the same New York Times article that I was. An imam is quoted as saying that Dr. Hasan “wanted a woman who prayed five times a day and wears a hijab, and maybe the women he met were not complying with those things”. The same article quotes Nader Hasan, a cousin, saying that unhappiness about a potential deployment to Iraq or Afghanistan motivated Dr. Hasan’s violence. This struck me as odd. If Dr. Hasan wanted to meet pious Muslim women, wouldn’t an all-expenses paid trip to a country containing millions of such women be something for him to look forward to? Surely it is easier to find a hijab-wearing woman in Afghanistan than in Texas.

[August 2024 update: That last sentence probably isn’t true anymore…]

What’s it like over there for a medical doctor? One of my friends, a man in his 60s who went to Iraq with his reserve unit, sent me his war diary from 2005. Here are some excerpts (I’ve changed the names):

• [at a training and embarkation base in the U.S.] Now it is back on the bus for a trip to medical screening, finance paperwork, a meeting with Joe Smith (medical liaison employee) whose job it is to take care of the doctors. … it comes as no surprise that he is of little or no value. Add to that the fact that he doesn’t know this and he has all of the makings of a first rate government employee. One would think that with 131 groups before us, Joe would have the program down pat, have detailed handouts and guidance for everything from what to wear to where to play golf, but he doesn’t.
• [Next day] we are off to the dental clinic. My unit failed to send my dental records so I must repeat the bite wing and Panorex films even though I have a copy of my current physical showing the dental visit. The procedures require much waiting time for very little clinical time.
• [afternoon] we head for the CIF. This is the clothing issue point. The stations are numbered. Go from 1 to 19 and you get most of the things that you need and lots of things that you don’t need. I ask why I need snow boots and a shovel in the desert. Answer: because it is required. I now have three green duffel bags filled with stuff. There are uniforms, boots, body armor vest, flight suits, gas mask and best of all, a 9mm Beretta pistol. Since not everyone goes to Iraq, (some to Afghanistan, Kuwait, etc) it makes sense to issue thousands of dollars of unusable or unneeded equipment to everyone. They were all out of the body armor plates that go in the vest.
• [next day] What could be more fun than a 2 hour classroom lecture on how to shoot a pistol followed by a 45-minute bus ride to the range? The sun is bright and the air temp is 93 degrees. The first group of 15 soldiers goes to the line, performs their tasks (shooting computer controlled silhouette targets), and steps away for the second group. I join the second group since it is clear that it is only getting hotter and we must wear the armor until we finish qualifying. I ask for a civilian instructor to help me since I have little experience at the range. He does a great job for me; does everything but pull the trigger and I am an expert marksman. I even shoot, by accident, the distant target of the 2nd LT next to me.
• [next day] Starts at 7 AM for Death by PowerPoint presentation, a series of legal, cultural and ecumenical lectures designed to put the most alert person to sleep.
• [next day] Another beautiful day and this time it is a 4-hour course on map reading. With plotter and protractor we perform the basic functions that we teach our student pilots to do in about 20 minutes.
• [weekend] I sort out my three duffel bags of military equipment. It appears that two of them can stay behind in a rental locker that Dr Jones has hired for 4 months. I’ll pay my share so that I don’t have to schlep all of this to the desert.
• [next day] About 50 of us will take the 4-hour course on improvised explosive devices. We learn that a lot of the Iraqi bombs are made from US artillery shells. The plastic explosives are all from France. I ask the sergeant how it is possible that we are being attacked with our own friendly ordinance. I’ll let you know when I get an answer. The films are very interesting. The terrorists video most of their attacks to use as advertising. They also compensate their members based on the damage they wreak.
• [next day] Convoy class. The PowerPoint lectures are given by reservists on one year of active duty. They have never been to Iraq. Most of the slides are from the internet; few are from the Army. The take home message is that 50 percent of the deaths occur to truck passengers, either alone or in convoy.
• [about a week is spent playing golf, riding horses, and otherwise killing time waiting for a plane to the Gulf] Time is being wasted at the usual military rate.
• [after getting off the plane] We are in Kuwait. Considered by many to be a battle zone, at least for tax purposes, we are shuttled from here to there in buses protected by trucks with 50 caliber machine guns. Our first stop is RFI. This is a clothing issue point where we receive a mandatory allotment of “must have” gear for the war. I get knee pads, elbow pads, a new Kevlar helmet. Was there something wrong with the one that I got 2 weeks ago? I also get socks, tee shirts, Oakley sunglasses (you know the desert UV) and some other valuable stuff. This brings the price to $1,200. I sign for the goods. Amex is not needed because the Feds trust me not to lose the equipment. The clock keeps ticking, none of us sleeps. In fact, there is no place to sleep. We see a video tape from the Commanding General reiterating the rules of war. It includes commentary on drinking, drugs, sex and shooting the enemy. I don’t forget that we never shoot people; only “threats” or enemies.
• [on the ride from Kuwait to Iraq] The C-17 aircraft is a story by itself. What a beautiful $200 million machine. Great glass cockpit, FMS and highly capable autopilot. Holds 240,000 lbs of fuel and grosses at 560K. The amazing part is that it can get in and out of 3,000 feet. Every landing is power-on and the underside of the flaps is titanium allowing them to act as thrust diverters for landing. This is a great family aircraft because you can put your boat, SUV and a couple of hundred close friends and head to [a tiny airport in Maine] if the fuel burn doesn’t scare you.
• We get to [Iraq destination] in an hour and then hold near the airport for one hour while a mortar attack occurs. Watching the fireball explosions from 15,000 feet is enough to unnerve any clear headed person. Cleared to land we taxi in. I thank the crew profusely for their kindness to me and we make our way by bus to the passenger terminal. We finally get checked in as soldiers in Iraq. We do a little paperwork, dine at the Burger King at the PX and I get a room at the DVQ. Distinguished Visitor Quarters are for O-6 and above. A trailer with 2 bedrooms separated by a bathroom. I couldn’t be happier. I sleep on my down pillow until 8:30 AM.
• [next day] After lunch and a quick PX visit to buy soap we walk to the Air Force Hospital. It is a true combat support hospital. Air conditioned tents, all surgical specialties, trauma and ICU doctors. The Blackhawk lands on the pad. A bloody Iraqi is being bagged, then wheeled immediately to the ER. One of his legs is missing. The staff and their morale couldn’t be better.
• [afternoon] Bill [comrade from Guard unit] makes it back from his meeting. It is a warm reunion. He and his family are doing well. We have dinner and catch up on events past. One of the members of the unit has recently committed suicide. There was little warning. Apparently his wife was also in the Guard and was outside of his door when it occurred. Live ammunition, even in the hands of people unencumbered by mind altering substances, is always a risky procedure. This has not been the first suicide and certainly won’t be the last. Bill told me about the two Chinook helicopters that were totaled. One was destroyed in a whiteout sandstorm leading to a hard landing; no one was injured. The other was fuel management by pilot error. They switched tanks and flamed out both engines at 500 feet and 140 knots. The landing was very hard. The aircraft was crunched and there were three serious pilot injuries.
• [flight to field hospital] One of the boys drives me back to the flight line at 9 PM for the 10 PM departure in a Chinook that leaves at 10:40 PM. We fly at 500 feet AGL [above ground level]. The lights are out and I spend some time in the cockpit. I sit behind the left hand forward 50 cal machine gunner. They wear night vision goggles and would probably shoot anything that moves. There is a right hand forward gunner and another at the tail. Since I don’t consider the guns to be deterrents to ground fire, I can’t wait to get to [the destination]. About 40 minutes does the trick. We land, luggage is removed and we are greeted by the outgoing doctors. They are already at the airport for their flight that will leave in 2 hours.
• [next day] [Doctor soon to be rotating out] takes us on a giant walking tour of the Camp. We see everything including the mess hall, PX (new and quite nice), the gym, the administration building, the laundry, etc. I get 45 rounds of 9mm ammunition which I don’t need for two reasons. One, my magazines are lost in the other duffel bag [lost by charter carrier from U.S. to Kuwait]. Two, one bullet is sufficient if you need to use this gun. At any rate, I comply with the rules and put the stuff in my bureau drawer. At 6:30 PM I see two patients at sick call. The first is a 23 year old with severe low back pain, probably a slight disc herniation although there are no neurological sequellae. He is very nice and appreciative. I treat him conservatively with non steroidals and bed rest. The second is a 30 year old woman who arrives with her sergeant complaining of a right breast lump for three days. I do a thorough history and exam and find rib tenderness below the left and right breasts. On further questioning, she has just done a maximum amount of pushups for her PT test. There are no lumps. The sergeant insists that I order a mammogram. I explain that there is no need. She is adamant. I suggest that when she takes the patient home that she do the breast exam and bring her back if she finds a lump. If I needed a mammogram, I would have to fly the patient to Germany. I give her some non steroidals and wave adios.
• [next day] I awake to a beautiful sunrise. The air is clear and the crescent moon has disappeared. 7 AM is the perfect time to shower. I shave in the clinic bathroom and then go out the back door to the shower trailer. I am armed with soap, towel, shampoo and tooth brush. The water is just the right temperature. I wash my hair and rinse off. Then I use my new bar of Irish Spring soap. I have soap all over my body when the water runs out. I decide to dry off with my maroon towel. I have now experienced all three kinds of showers; without soap, without a towel and without water. Next up is the post deployment health survey. We see about 60 soldiers who are headed for home. It takes place in the auditorium and we use PDAs with an Army program. A series of questions and a signature by the doctor and the soldier is on his way. This is important in case there are medical problems after the soldier is discharged. We finish in time to have a leisurely lunch in the DFAC. The dining facility is run by KBR, a division of Haliburton, and staffed by civilians.
• [on a tour of the Combat Support Hospital] [a surgeon] tells me that a truck accidentally hit a young civilian employee who was running in a black shirt, black shorts and an Ipod. She has a C-1 fracture and missing teeth.
• [that evening] At 5 PM [doctor rotating out] takes us to the Commander’s Conference. The purpose of this daily conference is to report all of the logistical information about the unit to the commander. It is incredibly boring and drawn out. The only interesting part is the photo of the heat-triggered roadside bombs that were just discovered and x-rayed. These insurgents are sophisticated and educated people and we should not underestimate their ability to do damage. The junior officers must think that they are graded on quantity of speech. [another doctor] is sitting next to me and falls asleep. We will never need to attend another one of these although, of course, we are always welcome.
• [next day] My elegant private room in the windswept clinic is my home away from home. I have my own room with air conditioning, electric lights, and even a bed. Since I do not wear a watch, I have no need for an alarm clock. The sun pours through the glass taped windows early enough in the morning so that I can shave, shower and get to 7:30 AM sick call. Since we are overstaffed I do not need to worry about patient waiting time; there is none. The other night I watched [the young medics] try to start an IV to hydrate a young male soldier. I was concerned that he might need a transfusion before he was hydrated because of the mechanism of the teaching process. I saw a 28-year-old civilian this morning who herniated a disc putting armor on Humvees. Since we do not have an MRI or a CT for that matter, I suggested that he go back to the States.
• [Sunday] The day begins just after 3 AM when I awake to a warm room, turn on the air conditioner and go back to sleep. At 8 AM the hot sun filters through my window and I get out of bed. The shower trailer is filled with women this morning but, alas, no exhibitionism. The water is hot and the pressure is high. I recall the early days of Club Med and conclude that this is better. I primp myself, dress in my best flight suit, have some coffee and prepare for a day on call. [the doctor finishing call] turns over the keys to the narcotics cabinet to me. He suggests that we count them together; I decline and defer to his singular count. Think about it. If anyone is stealing narcotics then the count will be manipulated to be correct. If no one is stealing narcotics then the count will be correct. Either way, it is a waste of my time and I am preparing for Charlotte and Fred’s [two other doctors] waffle breakfast. Charlotte fires up the waffle maker, Fred makes first rate Starbuck’s coffee and people come and go at the dining room table in Fred’s room. They are alchemists, they turn lead into gold. They are lovely people. I have one half of a waffle, smoked salmon and some cream cheese.
• [seeing one of two patients while on call] The cardiologist from the combat support hospital calls me and asks me to see a young sergeant with pelvic pain. She was previously sent to [the big Air Force Hospital in Iraq] for an abdominal ultrasound which was negative. Her right lower quadrant pain continues to be a burden. I examine her with the young medic who does a nice job of history taking. She appears to have appendiceal adhesions and needs a laparoscopy. I call the internist and fill out the paperwork. The nearest laparoscope is in Qatar. Someone will decide what to do next. … I take a few minutes to ponder the following question: If no sex is permitted in the combat zone then why do I have 2 shelves filled with birth control pills and Depo Provera?
• [evening] It is my first night on call. I am entrusted with the keys to the safe which contains narcotics, ethyl alcohol, Ambien and some drugs that I have never heard of. After midnight a sergeant major comes in with significant right sided pain. The medic wakes me. I change into my scrubs because pajamas do not seem appropriate for this encounter. I take a thorough history and examine him carefully. There are no hard findings. Only his subjective response of pain in the right lateral abdominal wall. I diagnose musculoskeletal pain secondary to moving heavy duffel bags today. I have the medic administer 10 mg of subcutaneous morphine, prescribe Tylenol with codeine and bed rest and return to my room. I am asleep when the medic knocks on my door to tell me that the patient has received no relief. I repeat the dress up exercise and begin to wonder whether I have missed a serious underlying problem. Did he crack a rib? Did he lacerate his liver? I conclude that my diagnosis is correct but I transfer him by ambulance to the ER at the Combat Support Hospital. Better safe than sorry. I retire again.
• [Monday] I awake at 9:55 AM. The stress of the battle zone has forced me to sleep late. I shower and dress in my favorite flight suit. At lunch I ask a dentist how he got here. He took a 4 year Army scholarship to attend a state school (Minnesota) because he did not want to graduate with debt. He said that he really did not understand what he signed up for. This is his third year in the Army. It is one thing to join the Army because you want to be in the Army. It is an entirely different issue to join the Army as a medical professional for the money. After all, you can serve 2 years on an Indian reservation, not get shot at, and collect $500,000 including loan repayment. [the dentist] tells us that he is counting the days until he returns to his family.
• [afternoon] I see a sergeant who has a hearing deficit. He needs an audiology consult in Baghdad. This is not possible since he returns to New Jersey on Saturday. I fill out the consult papers for him. A surgeon removes a piece of shrapnel (old) from the left supraclavicular area of an Iraqi. Her incision is too small. I examine the incision and the fibrous tissue and suggest that she double the incision length and dissect from posterior to anterior. She gets it out and lets our endocrinologist suture the wound.
• [Tuesday] I am awake at about 7:45 AM when [a doctor] knocks on my door to tell me about a patient with pelvic/rectal pain. I shower and dress quickly and see the young sergeant with one of our incoming medics. The medic, who has recently finished her training and is a private, knows nothing about anatomy or simple history taking. I make her my project for today. The patient has violated general order number one which prohibits sex and alcohol in the theater. Luckily she is on the Pill because she has a significant case of PID. She had intercourse recently and is the proud recipient of a new infection. I remind her that our encounter is confidential and that no one will know about her medical record. I treat her with outpatient antibiotics and send the young medic to read. I will quiz her gently this afternoon.
• Two young men come to the clinic. They are machine gunners who sit on the top of Humvees with 50 caliber guns. They truly are the instruments of war. They are both happy to talk to me about what it is like to do their jobs. They look for bombs, insurgents, terrorists, etc. They are out on the road and constantly in harm’s way. They tell me that after a brief period of time you get used to being shot at and it becomes a funny event as long as you don’t get hit. They tell me that the body armor works well; one of their guys got his head blown off but his torso remained intact thanks to the armor.
• [evening] I take a quick shower and wash my hair before bed. The finely powdered sand is ubiquitous. I can taste it when I lie on my down pillow. Tonight I will sleep well.
• [Wednesday] Back at the clinic, I dive into the sick call collection of patients. I dispense more compassion then medication and try to give some comfort to the soldiers. I recall that I am here because they are here. This is in spite of the fact that I still don’t know why they are here.
• [evening before Yom Kippur] The Rabbi gives me a combat yarmulkah and I am honored to hold the Torah, There are about 8 of us [out of 14,000 Americans at this post]. Two lawyers, two pilots, a couple of young enlisted men and a young woman. She is going to run the lay service after the Rabbi returns to the States this weekend.
• [Thursday] It is 6:45 AM as I sit on the edge of my bed. The loud noise of the explosion causes me to take note. I find out later that it was an IED (improvised explosive device) detonated at the gate. There were no injuries; merely a wake up call. A young woman arrives with a lacerated lower eye lid. She had a bout with her clothing locker. Because of the location of the wound, I elect to suture it myself with 6-0 Nylon. My light comes from a handheld flashlight. The patient is cooperative and the result looks good. My next patient is brought in by one of the pilots that I met [during stateside training]. This Air Force man has a 2 cm deep scalp laceration which is actively bleeding. I turn the case over to the medic. I supervise her as she injects local anesthetic and places 4 interrupted absorbable sutures. Good result and we send him off without a helmet. The sergeant interrupts me as I write. A young woman with level 9 out of 10 pain is in the clinic. He asks if I will see her even though it is not sick call time. Of course I will as my mind races to think about how to handle a surgical emergency. Surprise, she irritated her vulva shaving and the pain is subsiding as we speak. She was crying and I reassure her that Tylenol or Motrin will carry the day. My medic is overwhelmed. It is her first exposure to this magnitude of pathology.
• [week later] I awaken to my first sand storm. The air in the room and hallway is thick with dust. The visibility outdoors is low IFR. Nothing appears to be flying. They tell me that this is a mild storm compared to the ones that last 3 or 4 days and you can’t see your hand in front of you. I shower but it only a matter of minutes before I am once again sand blasted. The flight suits have that fine dust all over them that gives the feeling of fine emery cloth.
• [trip to another base for a medical conference] I enjoy a cup of very good coffee, fill my pockets with camera, 9mm pistol and tooth brush and await the arrival of the Blackhawk. The helicopter ride is what flying is all about. We are at 50 to 100 feet over the ground and criss crossing the country side. It is a banner photo opportunity. I am at the left side window looking at farms, animals, highways with many trucks and cars and another Blackhawk in formation. The door gunners have their machine guns at the ready. The pilots have done this a thousand times and they are pros.
• [visit to Kuwait] The Kuwaitis have an infinite amount of money. This allows them to consume conspicuously without constraints. … The next stop is the Marina Mall. Every high end store in the inventory is here. Also on hand are Mercedes, Maserati and Jaguar without price tags. I must report that there are no book stores in the mall. Of course, why would you want a book store if you were rich for life and with no signs of running out of oil?
• [after returning to the U.S.] We go to the storage facility and to our rooms and gather up our stuff. … During the lunch hour we go to the processing center and get our hearing tests done. They too are not very busy but cannot complete our checkout since we must sit through a number of lectures on Friday. We pick up our medical and dental records for tomorrow and return to the warehouse to turn in our stuff. I turn in what I have and they tell me that all that remains is the pistol and its magazines and case. The sleeping bag appears to be mine to keep. They tell Jim that the record shows that he never received a weapon. He disagrees and plans to turn one in. Dave gets an extra set of body armor to keep. The record-keeping leaves something to be desired.
• [two days later] My back still hurts when I get up. I must have created the usual strain moving a duffel bag. I get some coffee brewed in the room and Todd and I head for the morning briefing sessions. As usual, they are of little value except for the extended medical coverage for the family for 180 days post-deployment. We then have to do the reverse SRP. This requires meeting with finance, getting a TB skin test, getting a hearing test. Drawing blood for HIV, etc.

As noted above, these excerpts were written by a doctor in his 60s in the year 2005, before the Surge and when the insurgency was at its most destructive. How common is it for a doctor that old to go to Iraq? I have two friends who are flight surgeons in National Guard units. Both are civilian MDs in their 60s. Both have gone to Iraq. At least one was offered the opportunity to retire rather than be deployed, but he elected to stay with the men that he had been supporting for 20 years.

[August 2024 Update: Due to the controversy around VP candidate Tim Walz retiring from the National Guard rather than deploy to Iraq, I asked the other doc whether he could have retired instead of going to the desert: “I could have retired in 1995, or any time thereafter. I deployed in 2005.”]

Related:

• “Taking Care of the Pilots: Air Surgeon Retires from ANG at Age 68” (104th Fighter Wing): “Keenan officially retired from the guard in October 2016 when he turned 68, which is the congressional directed age of mandatory separation for military health professionals. The maximum age to become an officer in the military is 35 years old, but there are exceptions and waiver processes for specialized career fields. Doctors can join the Air Force up to age 58. Keenan commissioned at the age of 61.”