Baghdad ER - Revisited
by Colonel Erin P. Edgar, September 2009
ABSTRACT: The China Dragons of the 28th Combat Support Hospital deployed in support of Operation IRAQI FREEDOM from September 2006 until November 2007. This combat tour was historic in many regards, and a good team became a great team while challenged with unprecedented casualty numbers and indirect fire attacks. Not only did they save thousands of lives; they helped advanced trauma medicine, as leading hospitals worldwide have benefitted from military initiatives in the areas of bleeding control and hemostatic resuscitation. Their service epitomizes the strides that have been made in military combat medicine, and their challenges highlight the areas in which our medical system can improve further.
(Editor's Note: We chose our paragraphs carefully. We have a responsibility to warn you that the full report is very graphic at points and can be disturbing, especially to those who have lost members of their families or friends. However, it's a powerful report, frank, informative and useful.)
China Dragon Casualties.
The nature of the combat in Operation IRAQI FREEDOM (OIF) in 2006 and 2007 made working at the CSH a fairly dangerous endeavor. Historically, a CSH was a relatively safe place to serve, but this tour was different. We had our first casualty after being in Baghdad for just a few days. A noncommissioned officer (NCO) was walking from the laundry facility to the hospital when a Kalashnikov 7.62 mm round fell from the sky and embedded in a muscle above his shoulder blade. Luckily he wasn’t seriously injured. It was either the result of celebratory fire (common after Iraqi soccer victories) or a battle that was occurring at a nearby Tigris River Bridge.
Indirect fire in the form of mortar shells and rockets rained down on the International Zone of Baghdad (the location of our hospital) on almost a daily basis. Our hospital took many direct hits. The dates and the number of the impacts are classified, but they resulted in the majority of our casualties. On one morning, a sleeping trailer suffered a direct hit that sent a fragment through many layers of the hospital, wounding an NCO. Thankfully, the night shift soldier who had been sleeping in the trailer heard the Counter Rocket, Artillery, and Mortar (C-RAM) warning system and quickly made his way to the bunker before impact.
Indirect fire attacks usually consisted of one to four rounds.
However, one summer afternoon we were under sustained bombardment for nearly 90 seconds. Well over 50 rounds impacted in our vicinity, and it appeared to be a rolling barrage down Haifa street right in front of our hospital. Captain Maria Ortiz and a fellow nurse were walking back from the embassy gym. Maria had begun an aggressive exercise regimen in hopes of surprising her fiancé upon redeployment by fitting into a size eight wedding gown. Both nurses heard the C-RAM alarm and hurried toward the nearest bunker, but the warning came too late. They were struck down by mortar fragments from a nearby impact. Within minutes, they were in our trauma bay thanks to Australian soldiers who witnessed their wounding. Despite aggressive measures to save her life, Maria died. Her wounds were fatal. She is the only nurse to be killed in combat since the Viet Nam War. If, prior to deployment, someone would have predicted that I would have 13 soldiers wounded in action and one killed, I would have laughed off such a prediction as inane. That kind of carnage did not happen in deployed CSHs. I pray it never happens again.
Managing Morale.
Shortly after arriving in Baghdad, I decided that one of my most important jobs as commander would be to monitor and, to the greatest extent possible, influence morale. High morale is a combat multiplier, but when it is low, it can mean the death of a unit. Indiscipline rises, and performance drops. My fellow CSH commander who had the mission of caring for security internees (prisoners) sent me some files covering his hospital’s morale initiatives and in one file was the “morale curve.” It was shaped like a “W.” In a standard 12-month deployment, morale starts off very high. Soldiers are excited to be in the fight and are getting their coveted combat patch for the right sleeve of their uniforms. Three or so months into the deployment, morale dips because soldiers are missing their families, and many realize that the mission is not as glamorous as they thought it would be. Mid-tour leave tends to bring morale back up as soldiers get to recharge their batteries and see loved ones. At about 9 months, it dips yet again for a variety of reasons. Many soldiers at this point who are experiencing family and/or financial problems loathe the notion of returning home soon to face those problems. Finally, as redeployment approaches morale increases as the “mission accomplished” attitude pervades the unit.
In late August of 2007, China Dragon morale was the lowest I had ever seen. Our modified “W” for an extended tour had predicted this, but the tour extension and Maria’s death had played pivotal roles. We had just said goodbye to our second batch of 6-month deployers and replaced them with the third batch of 40 personnel. I was wondering to what degree the extension was contributing. Studies of soldiers and marines have shown that the rate of post-traumatic stress disorder (PTSD) is higher in soldiers. Researchers hypothesize that Army 12-month tours are psychologically more damaging than Marine 7-month tours. My hypothesis was that 15 months was worse than 12, and I directed my research team to conduct a study on our soldiers. The study utilized a PTSD checklist and looked at a variety of factors. Interestingly, the PTSD rate was not significantly different in my long deployment population than in my short deployment population. Additionally, 15 percent of the task force scored at or above 50 points on the checklist, which is diagnostic of PTSD. I was surprised the number was so high, because most studies at the time suggested a lower percentage for the active Army as a whole. Furthermore, many experts had suggested that combat troops were at higher risk than combat service support troops such as ourselves. We didn’t study what made us so different or why our PTSD percentage was so high, but I believe our soldiers saw the daily carnage and experienced the combat vicariously through our patients. Additionally, the indirect fire attacks had many soldiers feeling uneasy and helpless without the ability to shoot back at our attackers. Shooting back might be cathartic. Interestingly, the factors most strongly associated with PTSD were sleeping difficulties and youth.
When one considers these two factors, they make sense. Sleep is the mechanism that recharges the body and brain. If the brain doesn’t get enough sleep, it becomes fragile and more prone to illness. Regarding youth, our 20-year-old soldiers were spending 6 percent of their young lives on this deployment compared to our 60-year-old soldiers who were investing just 2 percent. The older you are, the greater ability you have to apply perspective and context to traumatic situations.
The entire report in pdf form is at the Strategic Studies Institute, United States Army War College website: Read More...