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

Laurie Barclay, MD

March 28, 2003

March 28, 2003 — Editor's Note: With tensions mounting over hazardous conditions that may be encountered by U.S. troops in the Iraq war, some Congressmen are questioning whether the military is doing all it can to protect them. The legislators refer to a 2001 study from the General Accounting Office showing that 62% of gas masks and 90% of chemical and biological detectors issued to U.S. troops are defective. But according to the Pentagon, U.S. troops each carry two chemical protective suits with two more new-generation suits held in reserve, and they are adequately trained and equipped against chemical and biological weapons. How effective is U.S. protective gear, and what have we learned from Desert Storm to help protect our troops from whatever perils might beset them?

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 protective gear do the troops use, and how effective is that gear against chemical warfare and other weapons of mass destruction?

Col. Cloonan: People who question how well our troops are protected don't realize that we've got the best chemical gear in the world. The problem is that when you make any item of protective equipment, there's a tradeoff between the level of protection and the physiological cost of wearing that item. I could encase you in a butyl rubber suit, which would be highly effective. And if I were absolutely positive when and where troops would be exposed to noxious chemicals, that's what they would be wearing, for example, if they were entering an area known to be contaminated. But if you've ever been inside a butyl rubber suit, you'd know that there's no way you could wear it in desert heat and do any type of work at all — you'd be a heat casualty in 15 minutes.

The best, most top-of-the-line piece of chemical gear is worthless if it stays in the bag because it's too uncomfortable to wear. That's why we use the charcoal-impregnated suits to adsorb chemicals if troops have to wear them for any length of time, because they allow sweat to escape and cool the body down. No, they're not as effective as butyl rubber, but that's a moot point if the butyl rubber suit is going to stay inside the bag.

Medscape: What special precautions and protocols do medical personnel follow in the event of biological or chemical warfare?

Col. Cloonan: During the last Gulf War, the troops took pyridostigmine as pretreatment in the event of nerve gas exposure. It can be life-saving, allowing survival at five times the dose which is lethal otherwise. If I thought there was a definite threat, it would definitely be worth the cholinergic side effects of mild diarrhea and bronchospasm. During this war I don't think the troops are taking it — they're carrying antidote kitsinstead.

Medscape: Why aren't they pretreating with pyridostigmine this time?

Col. Cloonan: There was a big brouhaha after the first Gulf War about giving the troops an "experimental" drug. Actually, as you know, pyridostigmine has been around a long time; it's just that this is an off-label use for an FDA-approved drug. There's no ethical way the appropriate study could be done. In peace-time, are you going to deliberately expose individuals to nerve gas? In wartime, are you not going to give all troops what you think will protect them the best? It's like the anthrax vaccine, which is FDA-approved for cutaneous anthrax but will never be for inhalation anthrax, because that condition is almost unheard of in a natural state, so there's no way to gather data. We have convincing animal data, but there will never be a human study of the anthrax vaccine.

Medscape: Do U.S. doctors and medics treat injured Iraqi troops?

Col. Cloonan: Yes. According to the Geneva Convention, Iraqi prisoners-of-war must get exactly the same medical treatment that we give our own troops, so that's never an issue. The problem arises not with injured prisoners, but with injured civilians. We do treat them on a case-by-case basis, but we have to be very careful. If we use up all our medical resources treating civilians, we can't take care of our own casualties.

Medscape: In a combat situation or other emergency involving high volume and severity of injuries or illness, how are injured troops triaged most effectively, and how are scarce resources, including medical personnel time, supplies, and blood products, best allocated?

Col. Cloonan: If you're at the point of having to do triage, then by definition there are more demands on resources than there are available resources. In an overwhelming combat situation, you might not be able to treat those who are critically injured because you know they're not going to survive. By treating them you might use up resources that could save someone else's life who would die otherwise. All medical personnel are trained in making these types of decisions, but it's one thing to be trained, and another thing to actually have to do it. Thankfully, it's not an issue now because our casualty rates are so low.

Medscape: Is there any backup or support from electronic medical information resources, such as Internet access and/or email communication with medical experts not in Iraq?

Col. Cloonan: The technology goes pretty far forward, but at a certain point, there are operational security concerns. If you're at a fixed facility with a land line, then of course there is Internet capability, but in the field, the only access is via satellite. The priority for use of the satellite link goes to the line commander doing the fight, and he's likely to take a dim view of a doctor tying up his access doing a Medline search.

Medscape: To what extent are lessons learned from emergency medicine during the Gulf War applicable to this war? What knowledge derived from that war experience will be most useful in this war? What significant differences between the two wars will have the greatest impact on anticipated casualties in this war?

Col. Cloonan: At the individual medic level over the past 10 years, there's been a real shift in how we're managing casualties. There's been a real recognition that you can't provide real medical care on the front line in the same way as you would in downtown Los Angeles, where you have a well-equipped ambulance and at least two medical personnel for each injured patient. In civilian situations, transport distances are very small, no one is shooting at you, and you don't have to crouch down while dragging the patient to safety.

In the combat situation, first you have to get yourself and the patient out of the line of fire. In the Vietnam war, of 50,000 deaths, 10% — 5,000 people — were killed while they were trying to recover someone else. That's a horrendous statistic, so the first priority is to do it safely. In Black Hawk Down, there's a great scene where you have highly qualified, fairly intelligent people trying to put on a C-collar and trying to start an IV on an injured soldier in the middle of the road. Then you hear shots and see puffs of dirt kicking up from the road and you realize that they're being shot at by the enemy while they're trying to do medical care out in the open. The better part of valor was to get the heck out of the middle of the street.

We train these guys to civilian standards, but if they do what they've been trained to do in a combat situation, they're going to be killed. So in the Special Operations Combat Medic course, we have to unteach them a little, to be sure they get to safety first. If you look at deaths from combat injuries, more than half are from bleeding to death. Most of the others are head injuries from penetrating cranial wounds, and 90% of those are not salvageable anyway. So hemorrhage control is a critical issue. Now, we teach the medics to get themselves and the injured person out of the line of fire, and to put a tourniquet on immediately as a temporizing measure to keep the patient from bleeding to death. As they keep evacuating and pulling back to a safer location, they can try to control the hemorrhage by using dressings and other less hazardous means, and then they may be able to release the tourniquet.

One of the major differences between this war and earlier wars is the need for long-distance transport. I get so angry when I hear people complaining about how slowly this war is going. People who say that are real idiots. This is the fastest war in the history of the world. Before Desert Storm, troops were traveling 30 miles a day maximum. Now, they're traveling hundreds of miles a day. The problem with that is that they outrun their own medical support, and that they have much longer evacuation distances. They push the limits of helicopter flight time, which is more than two hours. So the greatest advances have had to be in en route medical care, with increased use of Forward Surgical Teams, which are highly mobile.

Reviewed by Gary D. Vogin, MD


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