Combat Medicine in Iraq, Part I: An Expert Interview With Col. Cliff Cloonan, MD

Laurie Barclay, MD

March 28, 2003

March 28, 2003 — Editor's Note: As U.S. troops advance through Iraq into Baghdad, their medical support system is a lifeline enabling them to survive enemy fire, extreme desert conditions, and even routine coughs, colds, sprains, and strains that also plague civilians. Who provides this vital support, what type of training do they receive, and how are they organized? Based on the first Gulf War experience, how can clinicians best cope with anticipated health hazards, and how will this war be different?

To find out, Medscape's Laurie Barclay interviewed Col. Cliff Cloonan, MD, chairman of military and emergency medicine at F. Edward Hébert School of Medicine, the military medical school at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. His other experience has included serving as an enlisted soldier and Special Forces medic, registered nurse, flight surgeon in Korea with the 43rd MASH; emergency medicine physician, volunteer, with the Forward Surgical Team of the 44th Medical Brigade at Howard Air Force Base in Panama during Operation Just Cause; head of the Tripler Hospital Emergency Medical Response Team providing emergency medical backup for Johnston Island, a major chemical weapons storage site in the Pacific; division surgeon for the 2nd Infantry Division in Uijongbu, South Korea; and chief of emergency medical services at the 121 General Hospital in Seoul. He has served as the chief of the emergency department at Womack Army Medical Center, Fort Bragg, and dean of the Joint Special Operations Medical Training Center, where he taught soldiers to be Special Forces medics capable of practicing without direct physician supervision.

Medscape: What type of training do medical personnel have before serving on the front lines in Iraq?

Col. Cloonan: It varies considerably, because medical care on the battlefield is delivered in an echelon system. Each troop is trained in first aid during basic training so that he can tend to his own injury or that of his buddy.

Around 1985 or 1988 we introduced the Combat Life Saver Program (CLSP), which was extracted from Israeli recognition of the need for an intermediate level of care between the injured troop and the medic, essentially advanced first aid. The idea is to have 18% to 20% of combatants trained in the CLSP so that there'll be one individual on every vehicle who could provide an elevated level of medical care. They take a four-day course and carry an aid bag with greater quantities of tourniquets, dressings, and other supplies than each troop carries for personal use, as well as additional supplies so that they can administer intravenous fluids.

Over the past five to six years, there has been a revolutionary change in how we train the basic medic, now called "91 Whiskey" and formerly called "91 Bravo." We've always trained them in combat medical care, but recently we've increased their ability to operate independently in combat outside of a hospital setting. It's now required that they be qualified in basic EMT at the National Registry Level, although they also get additional training.

The Special Operations Combat Medic is the most highly trained enlisted person, with more than one year of training at Fort Bragg, and EMT certification at the paramedic level. The Special Forces Medics have six months' additional training so that they can function in some aspects as a physician, performing resuscitation, amputation, and some basic surgery.

Medscape: What role do physician assistants and physicians play in combat medicine, and how are they integrated into the medical support structure?

Col. Cloonan: The physician assistants (PA) are the individuals who primarily man the very far forward medical units. They are licensed healthcare professionals trained in advanced trauma life support, with additional training in resuscitation and stabilization. Much of their day-to-day activities involves sick call.

The PAs are positioned at a unit called a Battalion Aid Station. There may also be some junior doctors there, especially in the Marines, who have completed their internship but not their residency. They're called "batallion surgeons" but that's a misnomer, like a "flight surgeon" who doesn't do any surgery. However, they put in chest tubes for pneumothorax, start IVs, and stabilize fractures for transport.

The next level is the Medical Company, which does not really address combat casualties but brings forward specialties, like a dentist, LPN, doctor. Their function is to provide medical support, like tooth extraction, x-rays, treating pneumonia, colds, or sprain/strain.

The next level has developed since the first Gulf War — the Forward Surgical Team, consisting of one or two general surgeons, one orthopaedic surgeon, one nurse anesthetist, some senior enlisted NCOs, and more junior people. They usually have two operating tables and eight beds. They may be co-located with the Medical Company, which is a great advantage because the Medical Company can provide the Forward Surgical Team with additional beds and manpower.

The Forward Surgical Teams are fairly robust on doing a fair number of surgeries, but since they only have two surgeons, it doesn't take too long before you burn out their capacity to operate continuously within a 24-hour period. But the main problem they encounter is that they rely on their ability to rapidly evacuate patients to the rear. Because they are such small units, if they can't co-locate with a Medical Company, they rapidly use up their capacity to do surgery on post-op care.

That brings us to the next link, which was developed at the end of Panama and the first Gulf War — the Critical Care Aeromedical Transport Teams (CCATT) for very far forward evacuation. Once the patient is operated, the CCATT transports and cares for him as he is evacuated to the rear. Throughout modern warfare, we have never transported a patient until he is stable; now, with the CCAT, you can practically wheel a patient off the operating table into the aircraft for a six- to 12-hour flight. Essentially, it's an ICU in the air. This is of major importance because it allows the military to limit the total amount of medical assets coming into the combat zone. Before, we needed many beds on the ground in the combat zone; now, we can stabilize casualties very quickly, operate on them immediately if needed, and transport them by CCATT within 24 hours after surgery. The Army has developed similar teams for helicopter transport.

The Combat Support Hospital varies in size but usually is about 200 beds, with significant medical and surgical capability. They have computed tomography but not magnetic resonance imaging, and most surgical specialties except neurosurgery and cardiothoracic surgery.

Medscape: What special equipment or supplies unique to the Iraq war situation do these medical units carry?

Col. Cloonan: Since World War II, we've been able to bring some technologies further forward with the advancing combatants, but the basic surgical procedures are the same. The physical facilities look better now, so even though you might be inside a tent, it's air conditioned and it's got decent flooring in some sections. If you looked at side-by-side pictures of a combat operating room compared with a civilian OR, you might not be able to spot any differences.

Medscape: What types of wounds are medical personnel most likely to encounter?

Col. Cloonan: Although we train our doctors in major trauma centers whenever possible, preferably those that see a lot of street crime, most of what doctors see in these centers is blunt trauma, like a car accident, or penetrating trauma from a knife or gunshot wound from a handgun. On the battlefield, it's a whole different story. Handguns are virtually unheard of — shots are mostly from AK47s or other high-velocity rifles. The great majority of casualties are wounds they'll never see in peace-time: mostly a combination of fragment, burn, and blast wounds from grenades and land mines. We do the best we can to prepare them with simulators and pictures, but most will have to treat injuries they've never seen before. If you've never seen the effect of an antipersonnel mine or a rocket-propelled grenade, you're going to be in for a big surprise. Your readers might want to see Black Hawk Down — it's a highly accurate depiction of the types of wounds we see.

Medscape: How often do medical personnel treat desert-related conditions, such as eye irritation from sandstorms, dehydration, heat stroke, scorpion and snake bite?

Col. Cloonan: Actually, they treat a lot more of these than they do surgical wounds. Of about 250,000 troops stationed in Iraq, most of the deaths have been accidental, from helicopter crashes or friendly fire. The likelihood of twisting your ankle is a lot greater than of having a battle wound.

Although we issue protective eyewear to the troops, they don't always wear it, so we do treat a lot of corneal abrasions. Most snakes won't bother you if you don't bother them. But a scorpion can sneak into your sleeping bag -- I just heard about a soldier who got bit on the neck. We teach them to shake out their boots before putting them on, because a scorpion can hide in there.

Medscape: Does working in desert conditions while traveling pose unique challenges, such as maintaining a clean field during surgery, or preventing shock in injured patients exposed to extremes of heat and cold?

Col. Cloonan: Most wars are fought in uncomfortable, dirty, nasty environments, but that's just where we operate. In Korea we had the freezing cold; in Iraq we have the blazing heat and windstorms blowing sand in your eyes. We tend not to fight wars in Hawaii.

Reviewed by Gary D. Vogin, MD

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