Psychiatrists Get Insider's View of Combat Stress

Col. Thomas Malone, M.C., chief of forensic psychiatry at Walter Reed Army Medical Center, had an existential moment during his six-month assignment to the 28th Combat Support Hospital (CSH) in Baghdad last fall.

“Like most of the hospital staff, I saw frequent enemy rocket attacks in the distance and blocked them out. However, I couldn't ignore the sound of an incoming missile nearby that exploded only two blocks from me. The possibility of being killed in Iraq became more real, and I had nightmares for a few nights,” said Malone.

He continued, “I realized that I had suppressed my fears about my safety, which is a common coping mechanism that soldiers use. This experience gave me a new perspective on my patients' reactions.”

Malone and several other physicians and nurses from Walter Reed were deployed with the CSH or its subordinate field units in Iraq for up to a year ending in February. They spoke at the Lt. Col. Kenneth Artiss Symposium last month at Walter Reed (see story at right).

Despite frequent rocket attacks, extreme heat, and logistical problems, U.S. and allied soldiers, Iraqi enemy prisoners of war (EPWs), and certain Iraqi civilians received the same standard of medical care at the CSH in accordance with the Geneva Conventions, according to Maj. Matthew Brengman, M.C., a staff physician in the department of surgery at Walter Reed and a trauma surgeon assigned to the CSH in Iraq.

Brengman said, “Once the war started, I was concerned about my personal safety and whether my professional skills would measure up to the challenge of operating on combat-related injuries.”

He rose to the challenge, as did the other surgeons, who specialized in neurological, thoracic, and oral surgery. “This was the busiest combat support hospital since Vietnam,” said Malone.

This was the second time the 28th CSH had been deployed to Iraq in support of military operations. The first deployment was in 1990 to support Operation Desert Shield during Operation Desert Storm, according to the CSH's Web site. The CSH remained in Iraq for 30 days after the “termination of hostilities” to continue providing medical care to American soldiers and Iraqi prisoners of war. The second time the CSH stayed in Iraq for a year, most of it after major military operations ended. Many physicians complained to the CSH commander that a year was too long a deployment, and thus the Army is now making an effort to rotate physicians every six months, said CSH Commander Col. Beverly Pritchett, M.C., at the symposium.

Iraqi Children Injured

The CSH was authorized by the Army to treat anyone in Iraq needing medical care, not just Americans. “But, with limited resources, we had to decide which Iraqi civilians to treat on a case-by-case basis,” said Brengman.

He showed explicit slides of American soldiers and Iraqi EPWs and civilians with traumatic injuries and burns caused mainly by explosive devices including rocket-propelled grenades, mines, and bombs.

Iraqi families brought their often severely injured children to the CSH because local hospitals were damaged and supplies looted.

“I had worked in pediatric intensive care units in the States, so I knew what to do for burn victims. But when the burns covered 90 percent of their bodies and there was internal damage, we knew they would most likely die and did everything we could do to make them comfortable. As a physician, it was heartbreaking to watch these children die.”

He and Maj. Benjamin Gonzalez, M.C., assistant chief of emergency medicine at Walter Reed, said the deaths of Iraqi children affected them the most.

“I became emotionally numb and stopped caring about each individual patient. This became apparent to me after another Iraqi child died, and I didn't respond for a while to the nurse's questions about how to proceed,” said Gonzalez.

He also thought he would be returning home soon after President Bush declared on May 1, 2003, that major military operations had ended. “When the administration decided to extend the soldiers' tours of duty, this raised a huge credibility issue,” said Gonzalez.

Learning to Cope

The number of casualties in Iraq fell after the May 1 announcement. It rose in the fall, however, when insurgents began attacking U.S. forces, their allies, and lraqis trained by U.S. forces.

A high-casualty day was November 2, 2003, recalled CSH staff at the symposium. Two Army Chinook helicopters were hit by enemy fire south of Fallujah, killing 16 American soldiers and wounding 20, said Gonzalez.

“There was chaos in the ER when the wounded all arrived at the same time. Everyone including nonemergency medical technicians helped out,” said Gonzalez.

The camaraderie among the CSH staff and occasional light-hearted moments helped him get through his deployment. “I also liked seeing smiles on Iraqi faces after they received our medical care,” said Gonzalez.

Malone said the greatest hardship for him was being separated from his family for six months. “It helped that we could communicate by e-mail frequently and by phone occasionally. I cherished the cards and letters my family sent me,” said Malone.

A description of the 28th CSH is posted online at<www.bragg.army/mil-44md/28th/default.htm>.▪