ASA October 2003 Newsletter

The United States sent 300,000 troops overseas this year for Operation Iraqi Freedom while others remained on duty in Afghanistan for Operation Enduring Freedom. Anesthesiologists accompanied the troops into each war zone with at least 16 army anesthesiologists serving in Iraq. All served their country well, and many are still serving under hostile conditions.

Scott M. Croll, M.D., for instance, was deployed in early March to Kuwait with surgeons and other active-duty professionals of the 28th Combat Support Hospital. When fighting began, his group advanced into Iraq with the front-line forces, and by April 7 had arrived outside Baghdad. To get there, they rode in five-ton Army trucks, wore rubber suits and gas masks during missile attacks and ate dry foil-wrapped meals. Each truck carried 18 soldiers and medical supplies on the slow, bumpy, dusty, smoky, windy and hazardous trip [Figure 1].

Figure 1: Army trucks carrying a mobile hospital. Photo courtesy of Scott M. Croll, M.D.

About the trip, Maj. Croll comments, “Multiple times we donned our gas masks and went to MOPP-4 (Mission Oriented Protective Posture level 4) during SCUD attacks and other credible threats where the risk of chemical or biologic attack was high. These protective suits made the desert heat even more unbearable and increased the risk of dehydration and heat casualties. There were no restrooms or showers or beds or hot meals along the way. We passed many shepherds with sheep, goats and camels. When we passed Iraqi citizens, they invariably waved and smiled at us.” MOPP-4 designates the highest response status to possible nuclear, biologic or chemical attack.

Figure 2: Injured soldier arriving at the Combat Support Hospital. Photo courtesy of Scott M. Croll, M.D.

The Combat Support Hospital consisted of large tents erected at a desert site near the city. It included two operating rooms, two intensive care wards, one regular ward, a laboratory and radiology suite and a pharmacy. Dr. Croll and other members of the medical team slept in tents next to the hospital when they could. They treated soldiers for extremity wounds, hypovolemic shock, burns and other war injuries. The wounded arrived at all hours of the day and night [Figure 2]. During the month they spent outside Baghdad, they performed 200 operations, including many on Iraqis. Dr. Croll used general and regional anesthetic techniques for the variety of surgical procedures, including thoracic operations. An electrically powered generator supplied oxygen with sufficient pressure to power a Narkomed M anesthesia machine [Figure 3]. The sophistication of this tent operating room exceeded anything available in Baghdad hospitals, even prompting some surgical referrals. On the wards, anesthesiologists administered ketamine and midazolam intravenously for the many wound-dressing changes.

Figure 3: Tent operating room provided sophisticated care. Photo courtesy of Scott M. Croll, M.D.

Other anesthesiologists served at hospitals in Kuwait and on the hospital ship USNS Comfort, which was anchored in the Persian Gulf. They treated injured soldiers flown in by helicopter. Additional anesthesiologists worked at the military hospital in Landstuhl, Germany, where injured soldiers went for specialty care and stabilization to allow for their return to the U.S. mainland. Table 1 lists 16 active-duty anesthesiologists who were deployed to the Iraqi theater of operations. At least one reserve anesthesiologist was deployed to nearby Kuwait. Col. John H. Chiles, M.D., Army Anesthesiologist Consultant to the Surgeon General, reviewed the anesthesia care during the war and noted how well the Army, Navy and Air Force anesthesiologists deployed throughout the area worked together. He also praised the collegiality of army nurse anesthetists who also were deployed to forward surgical teams and combat support hospitals.

Table 1: Army Anesthesiologists Serving in Iraq

Colonel Larry T. Bourke, M.D.

Colonel Denver Perkins, M.D.

Lt. Colonel Stephen L. Bolt, M.D.

Lt. Colonel Eric H. Katz, M.D.

Lt. Colonel Joseph P. Miller, M.D.

Lt. Colonel Frederick V. Palmquist, M.D.

Major Archie Archevald, M.D.

Major Michael B. Berry, M.D.

Major Scott M. Croll, M.D.

Major Allan Hays, M.D.

Major John Hirsch, M.D.

Major Mark A. Meeks, M.D.

Major Christopher J. Niles, M.D.

Captain Kumudhini Hendrix, M.D.

Captain Grant Lynde, M.D.

Captain Joel W. McMasters, M.D.

In March the Army called me and other anesthesiologists serving in the military reserves to active duty. The Army assigned me to Walter Reed Army Medical Center in Washington, D.C., to backfill some anesthesiologists who had been deployed. Dr. Chiles, the chief of anesthesiology, was in Iraq, and David E. Longnecker, M.D., the assistant chief, was in Afghanistan.

This was the first time I had worked at Walter Reed. The sophisticated care and excellent training provided there impressed me. Walter Reed and Brooke Army Medical Center in San Antonio, Texas, house the two Army anesthesiology residency programs. Maj. Croll, for instance, trained at Walter Reed. To support the war, we received injured soldiers needing tertiary-level and rehabilitative care when they were stable enough to endure the trans-Atlantic flight.

While at Walter Reed, I anesthetized about 25 soldiers injured during Operation Iraqi Freedom, primarily for orthopedic procedures. Gunshots and land mines caused many of these injuries. Helping care for war-wounded soldiers made me feel good because I could help my country in a time of need, doing what I could do. Everyone treated the combat-injured soldiers like the heroes they were. Despite many life-altering injuries, these soldiers invariably had high morale.

Walter Reed provides excellent training to its residents. Five mornings per week, they receive didactic instruction, either a lecture, literature review or question-and-answer session. On the annual in-training examination last year, every Walter Reed resident by the end of the first year of training scored sufficiently high to have passed the written examination of the American Board of Anesthesiology. The Joint Commission on Accreditation of Healthcare Organizations has commended Walter Reed for its excellence, and U.S. News & World Report magazine featured it in its annual edition on the best hospitals in the country.

A particular strength of the Walter Reed program is regional anesthesia. It is used for approximately a quarter of all anesthetics. The operating room suite has a well-stocked regional anesthesia room that a separate team of anesthesiologists staffs daily. Since many battlefield anesthetics are administered under austere conditions, the sophistication of army anesthesiologists with regional anesthesia means they have an excellent technique for achieving both good operating conditions and prolonged pain relief there. The regional anesthesia team at Walter Reed has published several papers on their techniques and annually holds a review and cadaver workshop. President Clinton publicly revealed that he received regional anesthesia for a surgical procedure while in office. Many other prominent leaders receive regional anesthetics at Walter Reed. I was fortunate to have participated in the care of a few.

The Army and other military services offer scholarships to anesthesiology residents and opportunities for practicing anesthesiologists to join either the reserves or regular forces. Physical fitness and other standards apply. Anesthesiologists who qualify and join can practice their specialty and enjoy unique experiences. Sometimes they can help the country win a war.

Robert E. Johnstone, M.D. Johnstone, reservist, arriving at Walter Reed Army Medical Center.

Robert E. Johnstone, M.D., is Professor and Chair, Department of Anesthesiology, West Virginia University. He is the District Director from West Virginia and a Colonel in the United States Army Reserve.

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