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External fixator placed across a Grade IIIB distal humerus fracture in a 14-year-old Iraqi Army soldier. Reprinted with permission from Aid and Comfort to the Enemy: A Surgeon's View of the War in Iraq by C. Timothy Floyd, MD ©2010.

AAOS Now

Published 2/1/2011
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C. Timothy Floyd, MD

Giving aid and comfort to the enemy

A surgeon’s view of the war in Iraq

Although most of the world’s armies adopted humane policies for treating captured, wounded combatants in wartime after the 1864 Geneva Convention for the Amelioration of Wounded in Armies of the Field, George Washington and the Continental Congress already had established American values in early 1777. In the aftermath of the Battle of Princeton, Washington personally delivered two wounded British soldiers to his regimental surgeons declaring, “Treat them with humanity, and let them have no reason to complain of our copying the brutal example of the British army in their treatment of our unfortunate brethren.”

Although caring for opposition wounded does not comprise “aid and comfort to the enemy,” which Article 3, Section 3 of the U.S. Constitution defines as treason, it does describe a significant portion of U.S. activity in Iraq and Afghanistan. For that reason, I chose it as the ironic title of my new book, which describes in words and photographs my experience during the opening phases of the war in Iraq.

Treatment decisions and resources
In March 2003, I served as the sole orthopaedic surgeon in the Army’s 934th Forward Surgical Team (FST), a 20-person medical unit that operated out of a canvas tent and deployed often and rapidly. An FST must be able to break down, move to a new location and to be able to take wounded within one hour.

The FST is located within 10 kilometers of active battle area. We treated wounded at camps near Karbala, Baghdad, Balad, Baqubah, and Tikrit. We often arrived to take wounded at a base just after the Air Force and Army Rangers cleared it, but before other units arrived.

Most of the people we treated were not Coalition forces. We treated Iraqi Army, Republican Guard, Special Republican Guard, foreign terrorists, and unfortunate civilians caught in the crossfire.

Military medical doctrine calls for the humane and ethical treatment of all persons wounded in battle—regardless of politics, deeds, or ideology. Severity of wounds determines priority of treatment. Resources, such as external fixators or antibiotics, are dispensed according to need.

Most of the wounds we treated were of the extremities, perhaps because body armor protected the trunk or perhaps because people with chest or abdominal wounds rarely survived. I often placed external fixators without the aid of radiographs. On a single night, I treated six IIIB femur fractures, four IIIB tib/fib fractures, an open wrist, a IIIB humerus fracture, two severe foot injuries, and a number of other, less severe injuries. My three general surgery colleagues became adept at treating these wounds with me.

At one point we, and the medical company temporarily attached to us, ran out of morphine. Our closed canvas holding tent was filled with patients who had severe wounds and traumatic amputations. To change their dressings, we had to hold these patients down, reminding me of battlefield surgery descriptions from the American Civil War.

About 6 weeks into our mission, we were asked by Special Forces to treat a group of wounded Iranian terrorists who had been given sanctuary in Iraq. We had to drive through areas that would give rise to the insurgency and very near the farmhouse where Abu Musab Al-Zarkawi was killed.

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External fixator placed across a Grade IIIB distal humerus fracture in a 14-year-old Iraqi Army soldier. Reprinted with permission from Aid and Comfort to the Enemy: A Surgeon's View of the War in Iraq by C. Timothy Floyd, MD ©2010.
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Dr. Hal Walker examines an Iraqi child with cerebral palsy during a “housecall”; Army doctors later constructed a wheelchair for this child out of scraps found at Balad air base. Reprinted with permission from Aid and Comfort to the Enemy: A Surgeon's View of the War in Iraq by C. Timothy Floyd, MD ©2010.
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Surgeons work on a wounded Republican Guard soldier near Karbala, Iraq. Reprinted with permission from Aid and Comfort to the Enemy: A Surgeon's View of the War in Iraq by C. Timothy Floyd, MD ©2010.
C. Timothy Floyd, MD, FACS Dr. Floyd is an AAOS fellow with the 934th Forward Surgical Team, U.S. Army Reserve. When not deployed, he practices at the Boise (Idaho) Orthopedic Clinic, where he specializes in spine surgery.

The Iranians were responsible for countless murders, assassinations, and bombings, yet the Western-educated physicians in the garrison were cordial and amiable. They were dedicated to the demise of the current Iranian government and the restoration of a free society, causing us to ponder the distinction between patriot and terrorist, especially as we considered the American overthrow of British rule during our own revolution.

It’s better now
Delivery of medical care in these theatres has improved dramatically since 2003. Allied forces have built several state-of-the-art hospitals that can withstand mortar and rocket attacks. The evacuation system has improved dramatically. Wounded American soldiers are almost immediately air evacuated to centers in Germany, after they have been stabilized at Combat Support Hospitals.

From a medical standpoint, devastating musculoskeletal injuries and traumatic brain injury (TBI) almost define the wars in Iraq and Afghanistan. As in previous wars, innovative treatments and improved comprehension of pathophysiology have arisen in response to new and evolving mechanisms of injury. An example is the recent discovery of diagnostic proteins found in the serum of patients with mild TBI. Other advances have been made in hemorrhage control, surgical débridement, and fracture stabilization.

Just like many others in the military, medical personnel are overburdened with multiple deployments. A small cadre of orthopaedic colleagues is giving selflessly to save lives and preserve function in wounded soldiers.

In addition to active-duty orthopaedic surgeons, a group of about 70 Reserve and Guard surgeons rotates in Iraq, Afghanistan, Germany, and, occasionally, in continental bases. This number represents less than one third of 1 percent of practicing orthopaedic surgeons and is shrinking.

To address this shortage, the armed services, especially the Army, have tried to minimize deployment disruptions. My deployment 7 years ago was open-ended; today, deployments are fixed at 90 days and predictably established at least a year in advance. The service obligation has been reduced from 8 years to 2 years for physicians aged 43 to 60 years who want to serve their country but not risk multiple absences from work and family.

Because deployments rarely are more often than every 24 months, physicians choosing the 2-year track will likely have just one deployment. The Department of Defense has also created strong financial incentives including loan repayment and large bonuses for those who choose to serve.

George Washington said, “Every citizen who enjoys the protection of a free government owes not only a proportion of his property, but even of his personal services to the defense of it.” Those words drove me to join the army at age 48 after 9/11. Many orthopaedic surgeons have given a hefty proportion of “property,” but very few have given “personal services” by serving in the military. My experience in Iraq was not only the most rewarding medical experience of my career, but working with individuals of supreme character in service to their country was one of my greatest life experiences.

I urge all orthopaedic surgeons to heed Washington’s words and talk to a medical recruiter to learn the options available to them.

Surgeons interested in more information should contact their local military medical recruiter or Trish Green at (800) 984-1610 or trishg@mediacross.com

Aid and Comfort to the Enemy: A Surgeon’s View of the War in Iraq will be available at the 2011 AAOS Annual Meeting from the Society of Military Orthopaedic Surgeons (SOMOS); all proceeds are donated to SOMOS.