ometimes the first few months of residency are as difficult and frustrating for the staff as they are for the residents. When helping a young Navy resident struggle through the details of “Guidelines for Perioperative Beta Blockade” or placement of an arterial catheter, however, realization dawns that some of us are probably not on the typical medical school-internship-residency track.

For example, my class of anesthesiology residents at Naval Medical Center Portsmouth in Virginia has more than 25 years of operational experience in the Navy. The physicians I served with during the invasion of Iraq, all of whom were straight out of internship except for one, garnered one Meritorious Service Medal, six Navy and Marine Corps Commendation Medals, three with Combat Vs for Valor, and four Strike/Flight Air Medals, among other awards. Our corpsmen well exceeded that number of medals, and many of them are back in Iraq serving second tours with the Marines. For many of us in Navy medicine, it is a different path to residency, and I would venture that our service is better for it.

Physicians Assigned to MAG 29 During OIF in 2003 • Lt. Christopher B. Cornelissen, D.O. Chief Resident, Anesthesia, Naval Medical Center San Diego • Lt. Greg McNabb, M.D. Resident, ENT, Naval Medical Center Portsmouth • Lt. Mike Clarke, M.D. Resident, Orthopedics, Naval Medical Center San Diego • Lt. Jane Lee, M.D. Resident, Medicine, University of Maryland • Lt. Craig Randall, M.D. Resident, Orthopedics, Naval Medical Center Portsmouth • Lt. Cmdr. Bill Padgett, M.D. Flight Surgeon, Aerospace Medicine Specialist, Naval Air Station, Patuxent River, Maryland • Lt. Cmdr. Joseph G. O’Brien, M.D. Resident, Anesthesia, Naval Medical Center Portsmouth

Anticipating Challenges
We first caught wind of potential operations during the summer of 2002. Being more than just physicians working in a clinic or residents trying to master a specialty, we had to be forward-thinking and flexible enough to plan for success during battle. Success for us was defined not by passing the in-service examination or impressing our staff with our procedural skills but by being able to medically screen and prepare 2,100 Marines and their aircraft to deploy nine time zones away to battle in a potentially nuclear, biologically or chemically contaminated war zone and treat all casualties that presented (including the enemy). On top of that, we were determined to bring home everyone in one piece.

The major task of our aircraft group was casualty evacuation, or CASEVAC. Preparing for this mission required foresight and perseverance by both our physicians and corpsmen. In short we took eight volunteer corpsmen from our clinic and put them (and ourselves to a certain extent) through a curriculum created in anticipation of the mission. We developed the curriculum, constructed the medical kits and pursued the training required, all while maintaining a low profile since the mission was still classified. This whole process was created and directed by three of our physicians with the guidance of a very valuable and experienced Navy Search-and-Rescue Chief Corpsman from Second Marine Expeditionary Forces Special Operations Training Group (II MEF, SOTG). Based on our efforts, II MEF now runs this course year-round as an official training course for CASEVAC corpsmen.

Getting Real
It was March 13, 2003, and up to this point, the mission had been a huge success. Our corpsmen had been through a rigorous training program in preparation for upcoming operations in Iraq. Tonight’s training flight was one of the final opportunities to “put it all together” in a realistic scenario, in a realistic environment. I was along for the ride to observe the product of their efforts. We had no idea how realistic it was going to get in the near future. For months we had been wrapping up our preparations for our mission in Iraq — CASEVAC. CASEVAC is concerned with moving wounded soldiers from the point of injury to higher levels of medical care. Since first arriving, our days and nights were filled with numerous drills. It was beginning to pay off. As we navigated our CH-46E Sea Knight through the northern deserts of Kuwait within sight of the Rumaylah oil fields (and possibly those entrenched to defend them), I observed through my night vision goggles (NVGs) my corpsmen triage and treat their wounded fellow corpsmen. Although not as well equipped, they worked by the greenish glow of their “lip lights.” All that they had trained for was now coming to fruition. Bleeding and airways had to be detected by feel, I.V.s placed and airways established by the faint green glow. Tonight they did it flawlessly and with cool efficiency. They got one break tonight though: no real I.V.s on their buddies as they had done numerous times previously. We had to save our supplies.

CH-46 Sea Knight

The confidence and satisfaction gained from yet another successful training drill began to fade in the face of reality as we were soon flying real CASEVAC missions in the Iraqi and Kuwaiti desert. One night, as we approached home field, we found ourselves caught in the middle of a sandstorm. There was no moon to guide us, and what had become familiar landmarks suddenly disappeared. Aircraft maneuvers became more abrupt, the radio chatter more tense, and the rules we had come to know became unworkable as our helicopter crews struggled to negotiate landings in zero visibility. As a Navy pilot for 11 years prior to medical school, I am now one of 24 physicians who has earned the qualification as a dual-designated aviator/flight surgeon. Qualified to pilot the CH-53E Super Stallion, I recognized my fellow pilots’ efforts in the cockpit and understood all too well what was happening. We were in extremis. Somehow the aircrews performed miracles that night. It was to become the first of many that they would accomplish in the coming months of flying during Operation Iraqi Freedom.

The laryngoscope is one of the many tools used to keep patients alive during a CASEVAC. Photo by Cpl. Annette M. Kyriakides.

Later that night, we all joked about how we got lost walking to the hangar after we had shut down “somewhere on the runway.” That night the cold “sandy” pizza and warm sodas tasted great while we joked about what fun it would be to look for our aircraft in the morning. We all knew that flying in Iraq was going to be tough, but instinctively we all knew it was going to get even tougher.

Sweating Bullets
Just shy of four weeks later … 150 knots and 50 feet over the desert floor. My fighter/attack buddies would laugh, that close to the ground and at top speed in a CH-53E Super Stallion helicopter, I was working hard piloting the 60,000 pounds of vibrating steel and titanium less than a second from impact. Obviously I was sweating bullets, and it was not just because the air temperature was approaching 100 degrees F. It was with mixed emotions when I was relieved as the copilot some 10 hours later with the sun sinking toward the shimmering Iraqi horizon. That mission, however, would continue into the night, running ordnance to special ops and explosive ordnance disposal units northwest of Baghdad. As a pilot, I was motivated to continue the mission; unfortunately, I was exhausted, dehydrated and did not have the NVG qualifications to continue. The squadron commanding officer (CO) would continue on with the mission as aircraft commander with a whole new crew. That was good since he was maintaining situational awareness of the mission while bringing in fresh personnel. That day I experienced firsthand what our Marine pilots were doing day and night for weeks now. As the group surgeon and senior flight surgeon for Marine Aircraft Group 29 (MAG 29), this experience left no doubt in my mind about the mental and physical stress our aircrews were enduring. The importance of our medical support for these warriors was crystal clear.

A CH-53E Super Stallion helicopter, assigned to the "Sea Horses" of Marine Medium Helicopter Squadron Two Six Five (HMM-265), flies near the Iraqi/Syrian Border. U.S. Marine Corps photo by Cpl. Christopher R. Rye.

Surviving Residency Takes on New Meaning
I write about these two flights, two of many that I flew as either assault support copilot or as CASEVAC provider during Operation Iraqi Freedom in the spring of 2003, in order to highlight what many Navy residents have accomplished prior to becoming “just” another resident at various programs around the country. My experiences in medicine and those of my colleagues in Navy operational medicine (affectionately known as “GMOs,” for general medical officers) are a little different than those of many of our civilian counterparts transitioning from internship to residency. During the invasion of Iraq, and for the previous two years following internship, I found myself “in charge” of six other Navy physicians and more than 20 corpsman assigned to Mag 29, of Second Marine Aircraft Wing, stationed at Marine Corps Air Station New River in Jacksonville, North Carolina. These five physicians and their corpsmen played an integral part in the mission of our aircraft group.

During an urgent casualty evacuation mission, a crew chief watches for enemy fire behind a .50 caliber machine gun. Photo by Cpl. Cullen J. Tiernan.

In country we operated out of tents in southwestern Iraq, the back of aircraft on the east side of Baghdad and out of backpacks in Tikrit. We treated our initial casualties on board the Saipan, an amphibious assault ship. We treated more than 500 Iraqis in a 6,000-year-old village on the border with Iran, and we responded to an aircraft crash in a minefield.

All told our CASEVAC corpsmen and GMOs flew numerous CASEVAC missions and moved more than 150 wounded combatants from the point of injury during our deployment. We brought everyone home. We had succeeded. Now all we had to do was survive residency….

Joseph G. O’Brien, Jr., M.D., Lt. Cmdr. Medical Corps, U.S. Navy Reserve, is a CA-3 Resident, Naval Medical Center Portsmouth, Virginia.