A Navy fleet surgical hospital. Photo by John H. Chiles, M.D.

n December 4, 2003, I was attending the annual Tri-Service Graduate Medical Education Board at the Hilton Hotel in Alexandria, Virginia. As the Anesthesiology Consultant to the Surgeon General of the Army, I was a part of the committee that selects residents and fellows for the upcoming academic year. We were returning from lunch when my pager went off. I returned the call, and a sergeant told me that the 31st Combat Support Hospital (CSH) in Fort Bliss, Texas, was being mobilized to go to Iraq and that I had to report to them in one week for a yearlong deployment.

One week?

Gone for a year?

After the initial shock, I realized that while the circumstances were not ideal, it would be a great honor and adventure to care for our wounded soldiers and marines who came into harm’s way.

The following week was a flurry of buying equipment and clothing, getting powers of attorney signed, visiting family for an early Christmas and then leaving for Fort Bliss. I had served with the 31st CSH during the United Nation mission to Haiti in 1995 and again briefly in early 2003 when we were mobilized to deploy to Iraq. We did not go in early 2003, but I knew what to expect. After another week of training, issuing of equipment and physical training, we got the chance to go home for Christmas. That interlude was over quickly, though, and we flew out of Fort Bliss on January 8, 2004.

The medical staff is busy with two concurrent operations in a combat support hospital. Photo by Scott M. Croll, M.D.

Into the Green Zone
We were structured to perform split operations; so my half went to Baghdad, and the other half went to the Balad Air Base 50 miles north of Baghdad. We replaced the 28th CSH from Fort Bragg, North Carolina, in Ibn Sina Hospital in the “Green Zone.” Ibn Sina is a small community hospital that was used by Saddam Hussein and his family plus the elite of the B’aath Party. Compared to a U.S. hospital, it is pretty austere. When Saddam’s son, Uday, was wounded in a failed assassination attempt, a CT and MRI scanner were added in addition to a cardiac catheterization laboratory and a modern physical therapy section.

The 31st CSH-Baghdad had a 77-bed capability (21 intensive care unit beds, 55 ward beds and one isolation bed). In 2004 it was the only hospital with level I trauma capability in theater. Although our numbers fluctuated, we averaged six general surgeons, three orthopedists, two neurosurgeons, two oral-maxillofacial surgeons, two emergency medicine physicians, five internists/family practitioners and one each CT surgeon, vascular surgeon, urologist, gynecologist, intensivist, radiologist, psychiatrist, neurologist and pathologist. We had two to four anesthesiologists and up to 11 nurse anesthetists. We could run three operating rooms and could double up in one room with another bed if needed. From January 28 to December 31, 2004, we performed 1,521 surgical cases on U.S./coalition casualties, 1,027 cases on Iraqi soldiers/civilians and 512 cases on Iraqi detainees, for a total of 3,060 operations. We had 13 mass-casualty events. At the same time, we had 17,652 out-patient and 3,919 dental visits. Not much time left for boredom.

Since I was the senior physician in the hospital, I was appointed as the Deputy Commander for Clinical Services (DCCS), the equivalent of the chief of staff at most hospitals. We deployed with only two anesthesiologists, which put a strain on my partner, Maj. Christopher J. Kochan, M.D., since I could only pull call two, maybe three, times a week. At the six-month mark, our physicians and nurse anesthetists rotated out, and our bench got deeper with three other anesthesiologists besides me. One of them also was an intensivist, Lt. Col. Kurt W. Grathwohl, M.D., and my other two companions were Col. Kevin J. Mork, M.D., and Maj. Andrew J. Foster, M.D. We had superior nurse anesthetists who were led by Lt. Col. Page Neville and then by Lt. Col. John Wong.

Daily Challenges
As the DCCS of a medical facility in an austere medical environment, there were daily challenges. We were evolving away from the traditional role of the CSH being in support of forces in contact with the enemy during movement. By the end of 2003, Iraq had become a static environment, with our mission being to support the troops, U.S. Embassy and contractors, wounded Iraqis and, to a limited extent, humanitarian cases. Much of my time was spent trying to get the necessary equipment and supplies to meet the expanded mission. One of our triumphs was the acquisition of a plateletpharesis machine. Due to the short shelf life of platelets, they were difficult to maintain. In general the blood product resupply system was outstanding, except for platelets. Before obtaining the plateletpharesis machine, we relied on the collection of fresh whole blood during critical situations because it provided us with the best source of clotting factors and platelets.

While platelets are not an issue in most trauma cases, when you need them, you cannot wait for a plane to fly them in. The plateletpharesis machine allowed us to draw plasma-rich platelets on a scheduled basis rather than the urgent requests in the middle of the night for whole-blood donors. That machine has had a profound effect on combat casualty care in Iraq.

Serious R&R
As busy as we were, we did find some time for rest and relaxation. On Wednesday and Saturday nights, the physicians would convene on the hospital roof to smoke cigars for an hour and then watch a movie. The choice of movies was serious business, and we had a committee that decided which movies would be shown for the upcoming month. Of all the movies shown, “Kill Bill” I and II were clear favorites.

Often we were the first surgical stop for casualties in a long evacuation and treatment chain, and we knew that we had to do it right for them to get to the next step and ultimately see their family and friends. I see these kids walk the halls of Walter Reed Army Medical Center every day and marvel at their positive attitudes and the support of their families. I am extremely proud to know that I played a small part in giving them a second chance at life.

John H. Chiles, M.D., Col., Medical Corps, U.S. Army, is Chief of Anesthesia and Operative Service, Walter Reed Army Medical Center, Washington, D.C., and former Anesthesiology Consultant to the Surgeon General of the Army.