Incidents that Shouldn’t Happen

Dear President Bush,

Sec. Donald Rumsfeld talked about the execution of innocent Iraqi civilians as an incident that shouldn’t happen, yet it did occur & on your shift. As a man who studies history, you are aware this kind of incident occurs in war. The Vietnam War saw My Lai where hundreds including women and children, were gathered and killed. The Korean War had refugees lined up by American troops and executed, recently revealed per senior military orders.

Were the killings at Haditha part of the system or an aberration? Sec. Rumsfeld says aberration, while the new Iraqi Prime Minister cites systemic abuses by coalition soldiers. Who is right? One really needs to know in order to address the problem correctly. If it is systemic then the major causes need to be identified and addressed. If it is an aberration, what different happened, what went wrong for this to occur?

Last week a different incident occurred, a long time friend of my wife’s passed away at the age of 41. He fell through the cracks of our health care system for the last two years and died on the operating table. This gentleman worked hard as a trainer at a health club despite his disability. Twenty years ago a car wreck left him in a wheelchair.

Two years ago our friend got a skin sore that would eventually kill him. It got better after one stint in the hospital but did not completely heal. He returned to work educating and encouraging people to improve their fitness. His wound got infected and he entered health care limbo.

Unable to work, he lost his health insurance. With Medicaid, area physicians did not line up to treat him. His infection worsened reaching down to his spine. As a result they had to remove the hardware that supported his back, turning our friend into a human jellyfish.

For the next three months my wife’s friend lay in a hospital bed while they tried to clear the infection. The time came for his hardware support to be reinstated and surgery scheduled. On one of his last phone calls he said “I’ll call you after surgery”. That call would never be made. He died on the operating table.

My wife spoke with friends at the hospital where her friend worked. A physical therapist said “He died because he fell through the cracks. He died from a ___ damn skin sore.” Our friend died from the predictable results of the system in place, just as the people in Haditha likely did.

I suggest you get better educated on systems, knowledge, variation and psychology, otherwise known as the four areas of profound knowledge. The fifth is their interaction. If leaders learn and apply this theory, maybe there will be fewer incidents. Peace.