Editor’s Note—The subject of the following special feature may seem at first glance to be an odd choice for Critical Care Alert. However, in this short essay, Dr. Crawford, an intensivist who recently switched from civilian academician to military clinician and teacher, illustrates how critical care in time of war remains a cooperative, multidisciplinary process and involves civilians as well as members of the military. This particular conflict—the war in the Persian Gulf—took place half a world away from most of the newsletter’s readers. However, this might not be the case in the future, and many of the challenges encountered—such as dealing with large numbers of patients with resistant Gram-negative infections—have relevance to everyone who works in an ICU, regardless of its location. —DJP
Operation Iraqi Freedom: Some Lessons Learned From the Gulf
By Stephen W. Crawford, MD
This is a personal account of military medicine in the recent conflict. It reflects a view from a relative newcomer to Navy medicine—me. I learned many important lessons about providing medical care to the participants and bystanders of war, about the character of those involved in all areas of the conflict, and about myself.
Late in my career in medicine, I resigned my professorship at a prominent university to accept a commission as a senior officer in the United States Navy Medical Corps. I pursued this for many reasons: a new challenge, a chance to teach pulmonary and critical care trainees in a different venue, and the opportunity to work with people clearly dedicated to camaraderie and providing service. During my deliberation about a career change, I watched the television images of the World Trade Center towers collapsing on September 11, 2001. I realized I had never served my country and owed my country for many good things in my life. I proudly took my commissioning oath a month later. Never did I anticipate that I would have the opportunity to serve in theater with the skills I have spent years teaching to others.
Operation Iraqi Freedom (OIF) changed life for many of us in the military. This was a large-scale conflict. Because many casualties were anticipated, the services’ medical communities were mobilized in force to provide the needed care. While many think this war did not involve the Navy to a great degree, this was a misconception. Many Navy ships provided air-support to the missions, missile launching platforms, naval blockade and interdiction, material support, and transport for Marine troops. Among these ships were numerous "small boys" (destroyers and frigates), several aircraft carriers, and 6 of the Navy’s 11 amphibious assault ships. These last are the size of World War II aircraft carriers and serve as troop transport for US Marines and their equipment. The flight decks serve as platforms for large helicopters and vertical take-off jets. In addition, the medical departments serve as hospitals for returning troops and each ship can provide up to 6 operating rooms and 17 ICU beds with lab and radiology support.
The Navy medical teams on the amphibious assault ships are called Fleet Surgical Teams. These are teams of physicians, a surgeon, anesthetist, nurses, corpsmen (the naval team for "medics"), and medical support personnel. When a large number of casualties are anticipated aboard the "amphibs," the Fleet Surgical Teams can be augmented with a Casualty Receiving & Treatment Ship (CRTS) team. This augmentation brings the total number of medical personnel aboard the amphib to more than 100.
Navy medicine supports military actions in other ways as well. Navy medical personnel man 2 hospital ships. These ships are converted oil tankers that provide floating high-level medical support (12 operating rooms, ICU and hospital beds) for up to 1000 patients. The hospital ship USNS Comfort deployed to the North Arabian Gulf (NAG) in support of OIF. Also, the Navy can deploy Fleet Hospitals anywhere in the world. These are mobile medical support facilities that serve as stationary hospitals within miles of frontlines. A colleague of mine was the critical care physician for a Fleet Hospital in southern Iraq. She told me harrowing tales of practicing medicine in tents with blowing sand, intolerable heat, and limited water rations.
The US Marines were to play a major role in the conflict and this meant Navy Medicine was to play a major role. The Navy not only has the transport ships for the Marines but they also provide all their medical support. No Marine unit undertakes any mission without personnel from Navy Medicine in their numbers. Navy Field Surgical Support Groups (FSSGs) accompany Marine battalions. The FSSG concept now includes the capabilities to provide surgical interventions (Shock Trauma Platoons) within minutes of the battlefield. The average battle casualty in OIF received surgical treatment in less than 1 hour and the rate of deaths due to war wounds was the lowest in the history of modern warfare. The importance and seriousness of this assignment for Navy personnel are highlighted by the deaths of 2 Navy corpsmen while tending to Marines within battle zones.
As the beginning of OIF drew near, I knew that I would be called on to leave the comfort of the large Medical Treatment Facility at which I worked in San Diego and deploy to the NAG on a CRTS as a critical care physician. After nearly 25 years in medicine, I tried to prepare to be a military doctor. When our team arrived aboard the USS Boxer, we worked feverishly to create a cohesive team that could effectively deal with the large influx of casualties we thought would be flown from the battlefield to our decks. The prospects were high for chemical and biological injuries, as well as the typical battle wounds. As I tried to sleep in my "rack" in the stateroom I shared, I listened to the sounds of flight crews on the flight deck directly above me, and I dreaded the thought of treating young, previously healthy soldiers and marines.
When the war began we watched the television images in the wardroom just as the rest of the world did; and we waited for casualties. For days we saw the Navy and Marine helicopter crews aboard our ship come and go from their missions into Iraq. I was in awe as young men and women with M-16 rifles over their shoulders and 9-mm pistols strapped to their legs coolly went about their "business," day and night. We heard some of their tales from the war zones. None of them thought any special or heroic about their actions. It was "just their job." In the meantime, we had very few casualties to treat and were getting restless. The casualties were fewer than expected and were not coming out to the medical facilities on the amphibs. Casualties were going to the hospital ship USNS Comfort. They were busy—very busy.
Finally, several surgeons, nurses, corpsmen, and critical care physicians were mobilized from various CRTS teams and we helicoptered over to help out. The dozens of patients in the ICUs aboard the hospital ship were the largest collection of sickest patients I had seen in my career. Patients ranged from coalition forces, to enemy combatants, to civilians injured both as a result of the war and routine illness and usual civilian accidents. For some of the wounded, it was unclear whether they were enemy combatants or not, or even if they were Iraqi citizens. Some of the combatants arrived from neighboring countries. All ages of patients were treated. Any patient brought to any coalition medical station in Iraq was stabilized, cared for and transported to the hospital ship if needed. This included abandoned children without obvious trauma. Since there were few functioning civilian medical facilities existing in Iraq, many were flown to the USNS Comfort. Possibly the most tragic among these were the more than half-dozen civilians with extensive burns who required mechanical ventilatory support. I am sure the "burn unit" aboard ship rivaled that in any severity of any major burn center in the States.
Coalition forces brought to the ship were an amazing group of individuals. Each with serious injuries requiring surgical support, they were quickly treated with a higher level of care than I would have thought possible aboard a ship at sea. These men, heroes every one of them in my mind, were humble and almost apologetic for their wounds. Medivac flights to land-based medical facilities closer to home were quickly arranged as soon as the wounded were stable.
The same movement of patients was not true for the civilians. There were few options for transport to other medical facilities in the region. The devastated Iraqi medical infrastructure was unable to care for many of these severely injured citizens. The inability to move patients through a system created a large workload aboard the ship. This situation created a strain not only on the system but also on the staff. The most memorable experience for me was the way the Navy physicians, nurses, support personnel, and corpsmen responded. Young men and women worked tirelessly under some of the most difficult situations with incredibly ill patients and never complained. Improvisation was the name of the day since materials were limited on the ship and the level and variety and ages of the patients were not anticipated completely. Certainly, it was not anticipated that patients (especially the children) would remain aboard as long as they did. Nurses, surgeons, physical therapists, and corpsmen became very creative in devising ways to tend to the variety of burns, injuries, and infections with limited supplies. Their grace under pressure and dedication to completing the mission was inspiring. I suspect it was only a relative lack of experience that allowed some of the more junior members of the crew to tolerate the conditions—they didn’t realize just how difficult the situations were! More than once I fell asleep with tears in my eyes as I thought about the plights of the patients and dedication of the crew.
An already difficult environment was made worse by the presence of a serious multidrug resistant Gram-negative bacterial infection of many of the wounded coming out of Iraq. The Acinetobacter organism appears to be endemic in that country. The infection was easily transmitted in the crowded patient areas and frequently caused sepsis in the more critically wounded. Infection control efforts compounded an already difficult situation. Resupplying the ship with sophisticated antibiotics tested the system and the physicians.
It is likely that the patients with these serious infections would not have survived to reach a higher level of care had they not been treated promptly near the battlefield. The routine use of broad-spectrum antibiotics may have been selected for specific virulent organisms. These infections may be the price of "success."
The Lessons I Learned
1. In war nothing goes as planned. Preparing for all contingencies is impossible and this tenet applies to medicine as well.
2. Humanitarian missions likely will dominate the medical mission and will likely involve children’s issues.
3. The typical war wounds are penetrating injuries and burns. This basic fact remains even though the tools of war change.
4. A key to improving survival in wartime is rapid transportation of casualties to higher levels of care.
5. The nature and types of infections continue to change, due to the rapidity of medical care at the front. Injuries that were previously fatal are now routinely treated quickly and prophylactic antibiotics given near the battlefield. The more wounded we save, the more we treat for serious infections we otherwise would not see.
6. Medical providers who are dedicated can accomplish amazing feats in urgent wartime situations with less than "ideal" equipment.
These experiences have changed my concept of what is required to care for the critically wounded. The dedication of the caregivers is paramount and trumps any technology.
Note: The views and opinions expressed are not necessarily those of the Department of Defense or the United States Navy.
1. MMWR Morb Mortal Wkly Rep. 2003;52(36):857-859.