had just completed my pre-retirement class to transition me from 22 years of active duty service to the private sector when the word came down from above. Oh, that word from above! I was receiving eight-month orders to 1st Medical Battalion, 1st Marine Expeditionary Force, Camp Pendleton, California. We would train in California, then on to sunny Iraq. Well, I guess retirement from the U.S. Navy would have to wait a little longer.

From that point, November 2005, to our departure date of late February 2006, my life involved not only getting myself ready to go to a combat zone but also preparing my family. Helping to simplify their lives while I’m on the other side of the world would go a long way to keeping me focused on my mission at hand in Iraq. To that end, my preparation went from reviewing wills to practice with the 9mm weapon to donning a gasmask. By early February, I had all my uniforms and gear, my family settled in on the home front and everything ready to go.

The CH-46 Helicopter is one of the workhorses in casualty transport.

Finally, after all the preparation and anticipation, we left Camp Pendleton in the early morning hours of Saturday, February 25, and by Monday evening, February 27, I was in my new home for the next seven months, Al Taqaddum, Iraq. Al Taqaddum, or simply TQ, is a large Iraqi air base that we presently inhabit. Besides the ground forces and air combat elements, we have a level 2 medical facility. We provided medical/surgical care in the hostile Al Anbar Province, the infamous “Sunni Triangle,” just west of Baghdad.

In the U.S. military, a level 2 facility is the first level where surgical intervention is performed. At TQ, we consisted of a Forward Resuscitative Surgical System and two Surgical Shock Trauma Platoons, which in total yielded a Surgical Shock Trauma Platoon, or SSTP. Our team consisted of two anesthesiologists, one nurse anesthetist, four general surgeons, one orthopedic surgeon, two emergency medicine physicians, two family medicine physicians, one general medical officer and one pediatric intensivist. In addition we had a number of nurses, some trained in emergency medicine, as well as general ward nurses. Rounding out the team was our most important component, the U.S. Navy corpsman. Our corpsmen, analogous to Army medics, performed duties such as general ward care, laboratory technician duties, blood bank management, radiographic imaging, anesthesia technician, postanesthesia care and operating room technician. Our corpsmen also were critical in assisting us in the initial resuscitation phase of trauma management. Our mission at TQ would never have been accomplished without the skill and dedication of these young, highly motivated Navy corpsmen.

Operating room at TQ.

The Narkomed M is our anesthesia machine at TQ.

Field operating room table at TQ.

Our facility at TQ was something out of “M*A*S*H,” the hit television series of the 1970s and ’80s. It consisted of multiple tents housing our resuscitation area, operating rooms, wards, laboratory and administrative spaces. The tents were environmentally controlled by large diesel generators, which were very high-maintenance machines. During the summer months when daytime temperatures reached 120-130 degrees, the air conditioning inside these tents was a 50-50 proposition at best. In each of the three operating rooms that I had at TQ, the anesthesia machine was the Narkomed M, coupled with a Vamos gas analyzer, and Propaq monitor. This array required very little space and was quite mobile. We also had forced-air warmers, fluid warmers and a level-one rapid transfuser. Overall I was set up quite well for major combat trauma.

Our patient mix included U.S. Marines, U.S. Army, U.S. National Guard, Iraqi Army, Iraqi Security Forces, civilians and insurgent combatants. During our tour in Iraq, we had a little more than 1,000 patient encounters, with 30 percent to 40 percent requiring surgery. The principles of resuscitation were those of permissive hypotension, i.e., “don’t pop the clot!” and those of surgical intervention consisted of damage control surgery. Damage control surgery strives to control bleeding, restore perfusion, control contamination and stabilize fractures. Occasionally more definitive surgery would be attempted, but the decision to undertake additional surgical intervention on any given patient was dictated by many additional factors. Some of these factors included stability of the patient, the number of additional patients requiring surgery, tactical situation, status of supplies and status of personnel. All combat trauma imaginable was seen at TQ, from minor penetrating extremity wounds to major thoraco-abdominal blast injuries from improvised explosive devices, or IEDs.

Additional unique circumstances on the frontlines in Iraq included laboratory and radiographic support, medical evacuation and the blood bank. Laboratory support was limited to complete blood count, basic urinalysis, electrolytes and I-Stat. Radiology consisted of digital radiography, but we lacked fluoroscopy, computed tomography and angiography. Our blood bank was well stocked with 30-40 units of O positive and 10 units of O negative at any given time. For the all-too-often massive transfusion case, however, we relied on the walking blood bank. This was critical, as we did not have the capability to maintain fresh frozen plasma, platelets or clotting factors. As soon as we made the decision that a patient would probably require greater than four to five units of blood, the walking blood bank was activated. The donors were active-duty U.S. personnel at Taqaddum, and the response was usually exceptional. I would usually receive the first unit of fresh, whole blood within one hour of activating the system, with 30-40 potential donors already lining up at our doors to continue the supply of blood.

Our severely injured patients who would require additional postoperative care beyond our capabilities were transported on to level 3 facilities in Baghdad or Balad, both of which were 20- to 30-minute helicopter flights. The additional care required on these flights was provided by our highly skilled enroute care nurses. These patients were usually intubated, status postresuscitation and surgery, requiring additional resources of blood, pain medications, anxiolytics and muscle relaxants, while in-flight. During our entire tour, we only had one patient expire in-flight, and this was a patient status post-IED blast with nonsurvivable wounds.

In August 2006, the Construction Battalion Unit at TQ (U.S. Navy builders) presented to our unit a brand new fixed medical facility to house TQ Surgical. It seemed like a move from the tents to this facility was similar to a move from a low-budget motel to a new five-star hotel. We now were blessed with dependable air conditioning, a fourth operating room, ample space in our resuscitation area, larger ward space and storage areas. We had become fond of and comfortable with our tent facility; however, the change to this new facility would be a significant upgrade for the TQ mission. By early September 2006, all the tents that were TQ Surgical had been dismantled, and all that remained was barren desert. On September 11, 2006, our chaplains led us in a short religious ceremony at the site. This ceremony was a fitting honor to all those brave men and women, coalition and Iraqi, who lost their lives there, despite heroic efforts by TQ Surgical.

A few days after our ceremony, we were on our way back to the United States, our mission at TQ now complete. We were loaded onto a C-130 aircraft from Iraq to Kuwait and then a commercial DC-11 for the long journey back to the United States. The flight back was one of excitement to return to our families as well as reflection on the incredible experience that was Iraq. Our unit at TQ had rapidly developed into a highly motivated and efficient team, providing exceptional surgical care for combat causalities. The TQ Surgical unit was a true representative of the U.S. Navy’s goal of pride and professionalism.

As for myself, I have been extremely fortunate over the past 22 years to have been given the opportunity to serve our great country and the U.S. Navy. After internship, I received training and the designation as a U.S. Navy Flight Surgeon and spent seven fantastic years in Naval Aviation as a “Flight Doc.” Following anesthesiology residency, I had a number of rewarding tours as an anesthesiologist, both stateside and overseas, in a variety of clinical settings. But the most rewarding tour for me, both personally and professionally, was my time in Al Taqaddum, Iraq, with the U.S. Marines. It was an absolute honor to have served there in my unit, and it is something that I will remember for the rest of my life.

Charles F. Adams, Jr., M.D., Cmdr., Medical Corps, U.S. Navy, is Staff Anesthesiologist/Flight Surgeon, Naval Medical Center Portsmouth, Virginia.