Living in a bunker, treating civilians

While arranging the Landstuhl Visiting Scholars Program, Richard F. Kyle, MD, and Andrew N. Pollak, MD, were granted a rare opportunity to spend a week working at the hospital at the Balad Airbase in northern Iraq. They hoped to determine whether “down range” medical facilities might benefit from a similar program.

“It was the experience of a lifetime,” says Dr. Pollak. “[The surgeons at Balad] were tremendously welcoming. It was wonderful camaraderie and an opportunity for both sides to learn an awful lot.”

From Germany, Drs. Kyle and Pollak boarded a C-17 cargo plane—the backbone of the military evacuation chain.

“It’s an unbelievable transport plane that moves cargo to Iraq and carries patients back,” says Dr. Kyle. “It can literally be transformed into a flying intensive care unit in a matter of minutes.”

Upon their arrival in Balad, Drs. Kyle and Pollak moved into an underground bunker that had been part of one of Saddam Hussein’s many palaces. The hospital itself was a brand new building, built to replace an existing tent hospital where temperatures in the operating room (OR) typically topped 90º F.

“The first surgeries in the new facility were performed on the day that we arrived,” explains Dr. Pollak. “It looked for all the world like a U.S. hospital, with the exception of the Ugandan security patrol armed with M-16s. We don’t see that in many U.S. hospitals.”

A highly efficient medical team
In contrast to Landstuhl, which is primarily military, patients in Balad were primarily civilians who had been injured by gunshots or improvised explosive devices (IEDs).

“The insurgents use bolts, nuts, glass, rocks, and whatever they can contrive—old door hinges that are all ground up, nails—in the IEDs,” explains Dr. Kyle. “That results in multiple small wounds in an extremity. Because of the energy, you really don’t know the extent of the soft-tissue damage, so there’s a lot of compartment syndrome. You have to do multiple débridements to make sure that the wound is clean. These are injuries that you just don’t see in the U.S. civilian population.

“The surgical team in Balad routinely consists of a neurosurgeon, a vascular surgeon, a general surgeon, and an orthopaedic surgeon, who are all working on multiple injuries simultaneously. It’s very well orchestrated. Everybody is in the hospital, ready to go at all times.”

“The efficiency of care delivery is phenomenal,” agrees Dr. Pollak. “I can’t say enough about the commitment of the U.S. medical personnel and the level of care that they’re providing. The Balad team—from the surgeons to the OR nurses and techs—were from Wilford Hall Medical Center in San Antonio, Texas. They work together on a day-to-day basis, know each other, and have a remarkable camaraderie and functionality.”

The condition of Iraqi civilians
Drs. Kyle and Pollak estimate that they performed about 30 surgeries during the week. One, a young girl about 6 years old, had a large defect on the anterior aspect of her tibia, with soft-tissue loss from a gunshot wound, recalls Dr. Kyle.

“We plated and stabilized the fractured tibia. A plastic surgeon used a gastrocnemius muscle flap to fill in the wound, and then applied a skin graft. Without the excellent care delivered at this military hospital, she could have lost her leg,” said Dr. Kyle.

“I think Americans don’t appreciate the condition of the Iraqi population overall,” says Dr. Pollak. “Many of the people that we saw had never worn shoes, and the number of people with chronic medical conditions that really aren’t seen in the United States was very high. It’s very different from any American population.”

A different need
Both Drs. Kyle and Pollak concluded that, given the conditions in Balad and the efficiency of the surgical teams, an in-theater visiting scholars program might not be the best use of resources.

“It’s feasible in Landstuhl because people can go for a week or two and deliver care and come back,” says Dr. Pollak. “You’d have to commit at least three weeks in Balad to make it worthwhile. In addition,” continues Dr. Pollak, “the quality of the trauma care being delivered by the U.S. military in Balad is high enough and the expertise level is high enough, that the risk/benefit ratio may not be worthwhile for civilian surgeons.”

Resources are another matter. “The Iraqi physicians—those who haven’t been killed—lack the resources to handle these horrific injuries,” says Dr. Pollak. “That’s a real need.”

Overall, we had a very good experience,” says Dr. Kyle. “I couldn’t have asked for more. The hospitality was great and the surgeons…we learned a lot from them and hopefully they learned a little bit from us. I think we developed relationships that will go a long way toward helping establish a dialog so we can really do some research into war extremity injuries.”