A Focus on KP HealthConnect
••Fall 2004/Vol. 8, No. 4

KP In The Community

Permanente Physicians in the Combat Zone
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By John Murray, MD; William Goldsmith, MD

As we have read in past issues of The Permanente Journal, Permanente clinicians have an extensive record of giving time back to their community. It is always interesting to hear how members of the Permanente family spend their time when not providing care in KP offices. The following are stories of two such physicians who have served their country in Iraq and Afghanistan. These Permanente physicians have agreed to share with our readers their experiences in these combat areas.

The first commentary is from John Murray, MD, the acting Chief of Emergency Services with the Hawaii Permanente Medical Group. Dr Murray served with a US Marine Corp surgical unit in Kuwait and in the town of An Najaf in Central Iraq. The second is from William Goldsmith, MD, a four-year per diem psychiatrist who was stationed in a flight medicine clinic in Uzbekistan and flew combat support flights to Afghanistan.

On behalf of our readers, I want to thank you both for your service to our country. We know this experience has had to be incredibly difficult for you and your family. Many thanks!

-- Lee Jacobs, MD, Section Editor

John Murray, MD--Operation Iraqi Freedom

	LCDR Murray (center) discusses arriving patients with other physicians.

By John Murray, MD

Permanente History
I am currently acting Chief of Emergency Services at Kaiser Permanente in Hawaii. Residency trained and board certified in Emergency Medicine, I have worked for the Hawaii Permanente Medical Group (HPMG) full time since September 1998. My wife Cindy and I have been married since 1997. She is a nurse and recently graduated with her degree in Culinary Arts.

Military Background
Being activated and deployed to Operation Iraqi Freedom was my first active duty experience.

In early 1997, I affiliated with the Navy Reserves while living in Pittsburgh, PA. I quickly found my way to a unit that provided medical support to the Marine Corps. The Marines receive their medical support from a specific subsection of Navy medical providers. Emergency Medicine physicians are sought as assets for this type of unit, so the arrangement has worked out well.

Upon relocating, I began to perform my required drill periods with the Fourth Force Reconnaissance Company Marine Reserve Unit in Hawaii. With the onset of Operation Iraqi Freedom, the entire Fourth Medical Battalion, my parent command, was activated, and most of us were deployed overseas.

Assignment
Initially we were deployed to northern Kuwait, where we manned Surgical Company "E," set up in the desert at Camp Coyote. After about six weeks in this location, a subset of us was moved north into Iraq. I spent about four months in Iraq attached to the 1st Battalion/ 7th Marine Regiment, mostly in and around the town of An Najaf in Central Iraq, among the holiest of sites for the Shi'a branch of the Muslim faith. This area was rarely highlighted on the news during most of my stay because it was fairly well controlled, though lately it has received a great deal of coverage as the epicenter of some of the most recent unrest.

Professional Experience
Initially I went into Kuwait as Officer in Charge (OIC) of an 80-person Advanced Party element of the activated reservists. By the time the war started, I was involved in sending replacement medical providers north into Iraq as well as planning the integration of our arriving personnel into the medical assets already in theater.

After the remainder of our battalion arrived, I moved back into a strictly clinical role. In the current model of operation, emergency physicians are utilized in one of two roles. One is in the Surgical Company Hospital Receiving Area, serving a function much like the emergency department of a typical hospital. The other role is in a smaller, more mobile unit called a Shock Trauma Platoon (STP), designed to bring more advanced medical capability out to the Marines in the field.

I served most of my initial month and a half working in the Surgical Company's "ER." Here we saw a mixture of traumatic injury (some weapons-related and an unfortunate number of accidents) and medical illnesses. The Surgical Company, although tent-based, contained a fairly high level of care, including digital x-ray, laboratory, operating "rooms," and bed space for about 180 patients. We mixed continued training for mass casualty care and more austere field operation with working in this clinical setting.

After about six to eight weeks, I was placed into Iraq as OIC for one of the Shock Trauma Platoons that was located with the 1/7 Marines in Najaf. Our group consisted of one ED physician (me), one PA, one ER nurse, and several corpsmen. In addition to providing care, we took part in attempts to assess and rehabilitate the local health care system. Assessments of local hospitals and clinics, teaching to local ambulance crews and hospital personnel, consultation and, at times, direct care of ill or injured Iraqi nationals and some assessment of local water and sewage systems took place.

Interaction with the local community was among the most challenging and rewarding of the tasks we undertook. Surprising to me was the fact that all of the physicians spoke English, having had their medical training in English within Iraq. The knowledge base was good, but the care was often hampered by a lack of supplies and equipment.

On one notable occasion, our interaction with the local health care system was more direct. Just prior to one of our expected rotation dates (there were a few that came and went without us leaving), a louder than usual explosion from the center of town jarred our afternoon. The assassination car bombing of one of the most influential Shi'a clerics at the Ali Shrine in Najaf brought with it a mass casualty incident involving Iraqi nationals. After security was assured, we had a chance to go into the major hospital in Najaf and offer some assistance. We had an opportunity to work in the local health care system during a most stressful time. In reflection, it was interesting that except for the fact that most of the people in the crowd gathered at the hospital held AK-47's, the basic challenges of such a disaster scenario did not differ that much from what we practice and drill for here within KP.

Personal Observations--Were Our News Reports Accurate?
Although my personal experience is now a bit dated, my observations did not match well with the predominant stories we were able to see on the news.

Overall at that time, I found the vast majority of Iraqis in the area we frequented to be friendly and happy to see the US presence. My view may be skewed because I was mostly in the Shi'a-dominated section of Iraq, an area that had been persecuted by Saddam's regime. Although at times frustrated by a lack of rapid progress toward what they expected to be the "spoils" of liberation, most were friendly. When we were poised to leave and turn over control to some of the other nations in the coalition, many were reluctant to see us and the security they felt in our presence go away.

The news media that we were eventually able to view at that time tended to emphasize the areas with sensational and negative happenings. Not much was seen of areas where some progress and relative calm were the norm. We did not see much of our area in the press except when bad things happened there.

Again, one notable occasion was in the somewhat tense days after the above assassination when the news media came to town in force. While sitting in our command center and able to watch some media coverage, we would hear of bad things we knew were not truly happening. At one point, they were so convincing that I actually had to go out to check for myself to verify which account was correct. Fortunately, my impression was accurate, but those watching television at home (including my wife) had no idea that was true.

Most Difficult Moment
Leaving my wife at the Honolulu Airport for the initial flight to California was the hardest part.

Thoughts on How This Experience Changed Me
This is a tougher question! The day-to-day hassles of traffic or other minor inconveniences no longer drive me as crazy. Most important, the time I get to spend with my wife, friends, and family are seen as more special.

Although these realizations are real and important, I have found that even after just a few months back home, I have started to forget "lessons." Part of returning to everyday life seemed to be putting the specific memories of my "vacation" in a "box" to be opened and examined at times. Although this may be healthy, it has the negative effect of not allowing me to apply the good lessons I've learned. Despite my experiences in Iraq, sometimes I still find myself saying, "Boy it's hot today," when it's only 90° instead of 126°!

William Goldsmith, MD--Uzbekistan

	My crew position.

By William Goldsmith, MD


Permanente History

I have been with Kaiser Permanente (KP) for about four years as a per diem psychiatrist. I have worked primarily in Lancaster, CA, for a while at Sherman Terrace, and did some Urgent Care at Panorama City. I am married, have two sons, two dogs, and one cat. I'm 65.

Military Background
I am a Lieutenant Colonel, Senior Flight Surgeon, 146th Medical Squadron California Air National Guard, and a veteran of the Vietnam and Gulf Wars.

Assignment
I was stationed for about six weeks in Uzbekistan at Karshi-Khanabad, a former Russian airbase now used by the Uzbek Air Force and the US. It is austere, with gravel roads and a tent city, with some permanent buildings and several more on the way. Kellogg, Brown, and Root, a Halliburton Company, runs the physical plant, water, power, mess and construction and does an excellent job. The food was great: on Saturday nights, it was steak or crablegs. The tents have air conditioning. There are hot water showers and some flush toilets.

	A C-130--Stay on the Runway--Danger--Mines.

Professional Experience
I practiced in a flight medicine clinic at Karshi-Khanabad, seeing mainly minor medical problems related to the dusty environment and many orthopedic injuries from the rocky terrain and sports, especially soccer. My only suture job was the result of a soccer injury. The hospital patients were managed in an Army MASH next door. A case of Henoch-Schönlein purpura was evacuated to Germany. I alternated the clinic time with flying about 18 combat and combat support missions to Afghanistan, Kyrgyzstan, and Pakistan on C-130 aircraft. There was little medical work on missions; I went mainly for experience. Flight surgeons are required to fly regularly to be aware of crew duties and stresses and thus are better able to determine if a crew member is fit to fly.

Personal Observations--Were our News Reports Accurate?
Morale was excellent. In my opinion, we should establish permanent bases in Iraq, Afghanistan, Uzbekistan, Pakistan, and Saudi Arabia to protect the US and not involve ourselves with the locals except as it relates to the safety and interests of our country. Seven California National Guard members have died in this war, so far, of 175 Guard and Reserve dead nationwide.

Most Difficult Moment
Leaving Uzbekistan. There was nowhere I would rather have been. I had this epiphany on the flight deck of a C-130 over Afghanistan.

Thoughts on How This Experience Changed Me
I'm glad I went and wish I could have done more.

Contrast Your Over-There Experiences in the Different ConflictsThis war, as was Vietnam, is frustrating with no clear victory in sight. Desert Storm was an incomplete victory, which paved the way for the sequel. I hate the cruel, ignorant, mindless enemy, though oddly we're not supposed to say so in this politically correct era. I hope I was of some help to our personnel and our country. I'd go again.

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