Citizen Surgeon: A Memoir

Citizen-Surgeon

Paul Bryan Roach

DISCLAIMER: These notes are written from memory. All names, details and quotes range from approximate to something in the spirit of what was said. They represent the views and perceptions of the author alone and not the views of the U.S. Navy or Department of Defense. In the interests of privacy, specific details have been changed throughout every scene. Wherever poetic license has been invoked it has been in the interest of clarifying the reader’s perception of events and has not invoked in the spirit of exaggeration — well, most times, at least. Misrepresentation of actual events, if there be any, would be the fault of the writer and not any of the other individuals mentioned in this book. All swearing is the product of the author’s two and a half decades of Naval service, and despite how it may at times appear under no circumstances should it be ascribed to other characters in the book.

Copyright ©2015 by Paul Bryan Roach

All rights reserved. This book or any portion thereof may not be reproduced or used in any manner whatsoever without the express written permission of the author except for the use of brief quotations in a book review.

Printed in the United States of America

First Printing, 2016

ISBN 978-0-9971387-0-2 print

ISBN 978-0-9971387-1-9 epub

Forest Park, IL 60130

www.paulbryanroach.com

ACKNOWLEDGEMENTS

I am proud of and grateful to the men and women of the 1st Med Battalion, Alpha Company, USMC, with whom I served at Camp Dwyer; the English, Scottish, Irish, Welsh and American personnel I was fortunate to work with at the Camp Bastion Role III Hospital; our Afghan translators who risked not only their lives but the lives of their families in order to work with us; and to our families who supported the war effort, and bravely carried on. Not a day passes where I don’t think of these people, of the troops we treated, of the civilians, of those who died, and of the individuals who care for or miss them. My sincere appreciation and acknowledgement goes to my editors Ralph Scott and Isabel Levine who worked very hard with me on every detail of the manuscript, as well as to my sister Cathaleen Filosa who was a tremendous help — great editors teach and they pull things out of you that you did not know you had. I am grateful to all my family, who patiently advised and encouraged me along. Lastly, I am most especially proud of and grateful to my wife Megan, and to my fine children, who have faithfully supported and served alongside me all these years.

Forward

For every injured or killed service member there is also a circle of family and friends directly affected by those wounds and a larger, additional circle of individuals who are in some way concerned or involved. If you have gotten this far in this book you are already part of that larger circle and the more concerned and involved you get, the closer you will come to its center.

The world is a difficult place. Freedom and civilization require a cadre of brave and dedicated individuals to defend us. These individuals get injured and killed in the course of it and must not be neglected or forgotten. If you are moved by what you read in this book or if you are moved by any piece of work regarding servicemembers and veterans composed by any other artist or reporter, please consider investing yourself in some way into any of the fine organizations that cater to our war veterans.

I am a U.S. Naval Officer, a physician whose life’s work culminated in a combat offensive with the U.S. Marines during the Summer of 2009 through Spring of 2010 in Helmand Province, Afghanistan, code-named Operation Moshtarak. If you include medical school, surgical training, military training, and non-combat tours, I was almost two decades in various forms of preparation for that deployment.

Whether in Army, Navy, or Air Force uniforms, we combat hospital assets represent a relatively small, highly-trained operational force. Depending upon who you include in the mix (US, Canadians, UK, Europeans, Australians; doctors, nurses, PA’s, medical service professionals, corpsmen and medics…) even at the peak of the Iraq and Afghanistan conflicts our numbers added up to less than several thousand troops. By comparison, the U.S. Special Operations Command has about 10,000-13,000 Special Forces at any one time . I prefer to think we combat hospital assets represent something like the special forces of the medical ranks, and that like the other special forces, our stories might be worth telling.

This particular story was written not because I was the greatest or most experienced physician in the military’s ranks, I am of course neither. It was written because I was capable of writing it, because I needed to write it, and, for those who are in position to record the history of an important event, it is an honor and a privilege to do so.

Table of Contents

Chapter One:

The Competition

Chapter Two:

Preparations

July, 1992, Rush Medical College, Chicago Illinois

Baltimore, Maryland, August 2001; a very brief look at General Surgery training:

About six years later the author is working at a Navy hospital in Virginia when he receives the call to deploy to Afghanistan. There follows a description of an Army course he attends in San Antonio, Texas, to prepare doctors and nurses for the types of injuries seen in combat:

After the medical training of TCMC, the author attends Combat Training at Marine Corps bases (Camp LeJeune and Camp Pendleton) prior to departure. Journal entry recorded Saturday August 16, 2009:

Friday, August 21, 2009:

March Air Force Base, California, Sunday October 25, 2009, our Alpha Company departs California on the first leg of its trip out to Afghanistan:

Chapter Three:

Balls Deep

The C-17 Globemaster; Sunday, November 2, 2009:

While mentally escaping the flight’s discomfitures, the author’s thoughts flash back to Oakland, California, June, 1995, as he was finishing his Surgical Internship and making ready to head out into the world:

The distant recollections fade out as the C-17 Globemaster heads further into Afghanistan on the night of Sunday, November 2, 2009:

The author’s thoughts escape again and return to Flight Surgery school. The date is back in November, 1995, and we are now at Whiting Air Field, Florida, executing flight lessons:

The memories fade away and the Globemaster descends in altitude, the author and his company prepare to land:

Chapter Four:

Camp Leatherneck

August, 2009, U.S. Marine Corps Camp Leatherneck, Helmand Province, Afghanistan:

August, 2009, Camp Leatherneck, Helmand Province, Afghanistan:

Chapter Five:

Camp Dwyer

Camp Dwyer, Helmand Province, Afghanistan:

August, 2009, Camp Dwyer, Helmand Province, Afghanistan; next morning, next impressions:

Chapter Six:

Alpha Surgical Company, Package Inbound

Camp Dwyer, Helmand Province, Afghanistan; August, 2009

A flashback to San Antonio, Texas; May, 1995, the author’s Surgical Internship:

Camp Dwyer, Helmand Province, Afghanistan. Alpha rotation’s first patient arrives. August, 2009:

Chapter Seven:

The Paradox

The author was 18 years old and in the living room of his childhood home, Oak Park, IL. July, 1985:

August, 2009, Camp Dwyer, Helmand Province, Afghanistan.

Chapter Eight:

Mission Creep

Camp Dwyer, Helmand Province, Afghanistan, first day after Bravo Company departed:

Improvised Explosive Devices:

The author recalls his IED training, in Camp Lejeune, North Carolina, prior to deploying to Afghanistan. The date is Saturday, August 16, 2009:

Camp Dwyer Role II, October 2009:

Local Customs; Camp Dwyer, November, 2009:

Chapter Nine:

Interlude

Camp Dwyer, Helmand Province; November, 2009:

The author recalls the first time he ever left his wife alone for a deployment; the scene of departure was O’Hare Airport, Chicago; the date, May of 1996:

Back in Camp Dwyer, Helmand Province, sitting in the outdoor weight room between the conex boxes and our helicopter landing pad, resting between sets of pull-ups and staring vacantly at the Army’s H-60 helicopters; the date is sometime in November, 2009:

Winnetka, Illinois; July, 1978:

Christmas Day, Camp Dwyer, December, 2009

Chapter Ten:

Camp Bastion

Camp Bastion, Helmand Province, Afghanistan; January 1st, 2014

After having had enough time to ruminate and more than enough of a history lesson we return to Camp Bastion Hospital, Helmand Province, Afghanistan; January 11th, 2010:

Camp Bastion, Helmand Province, Afghanistan: Monday, January 18th, 2010

Bastion, Feb 2010

Chapter Eleven:

Operation Moshtarak

Camp Bastion, Helmand Province, Afghanistan; Operation Moshtarak: Monday, February 22, 2010

At the front edge of the battle but before any casualties began arriving, flush with excitement and admittedly, some anxiety, the author indulges in one last reflection upon how it was that he ever reached this point in life. The setting is Roger’s Park, Chicago, when he was in college, and the date is November, 1988:

Camp Bastion, Operation Moshtarak:Monday, February 22, 2010

Camp Bastion, Operation Moshtarak:February 2010

Camp Bastion, Operation Moshtarak:March 2010

The author recalls his first civilian mass casualty as an attending; the setting is a tiny hospital on Sigonella NATO base, in Sicily, Italy; the date is December, 2003:

Little Speena Gul, Camp Bastion, January, 2010:

While stationed as a surgeon at a small Navy hospital in Sicily, we took the children on a short vacation to the lovely island of Lipari, Italy, July 2005:

Camp Bastion, Operation Moshtarak:March 2010

Chapter Twelve:

It’s Not Over Yet

Camp Bastion, Operation Moshtarak:March 2010

A few days later:

There is only here:

Camp Bastion, Operation Moshtarak / Camp Dwyer:March 2010

Disease Non-Battle Injury:

FRIENDS AND COMRADES:

Camp Dwyer, Helmand Province:March 2010

Camp Dwyer, Helmand Province:April 2010

Chapter Thirteen:

It’s Over

RIP TOA (May 3, 2010):

Pete’s Place:Friday, May 14, 2010 – Manas, Kyrgyzstan

Chapter Fourteen:

Citizen

Camp Pendleton Marine Corps Base, California; April 2010

About three months after arriving home; the date is July 5th, 2010; the author is back in Portsmouth, Virginia, serving his last few months there before he could permanently transfer to Chicago:

Flashback: Camp Bastion-

Aboard the U.S.S. New Orleans and in the Coral Sea, the author sails through the doldrums:

Afterward

Some years later, the author reflects upon Alpha Surgical Company and his Naval career.

We shall not cease from exploration

And the end of all our exploring

Will be to arrive where we started

And know the place for the first time.

FromLittle Gidding

T.S. Eliot

Chapter One:

The Competition

In Afghanistan our desert did not possess a single blade of grass. Everything was brown or tan or something in-between. Our lives were not so different, reduced in spectrum to the one, solitary element we brought to the mission. The ten thousand ordinary items which in society comprised our days, weeks, and months, those perennial items claiming our thoughts and attention, they had been stripped away. They did not fit into our sea-bags and there was no place for them in country.

We lived out of tents: tents for sleeping, tents for work, tents for daily mail and tents for Sunday mass. Our worldly possessions folded up neatly beneath our cots. We had scant contact with the outside world. There was nothing else for us to do and nobody else to do it with. Our company was comprised of corpsmen, Marines, nurses, doctors, and staff. We were Northerners, Southerners, Easterners, and Westerners. We were men and women. We were black and white or something in-between. We were brought together for this mission, for our troops, and for our individual desires to do something important and something meaningful for our country and with our lives.

I am home now, but memories of the deployment keep finding me:

— Standing inside a poorly lit tent in a foreign place, a ragged, muddy blast victim on a stretcher shrieks in agony and scratches at life with desperate, shredded limbs

— An Afghan child struck by a Hellfire missile, skin bleeding head to toe from shrapnel wounds and we cut her open stem-to-stern but Death steals her abruptly from our hard-pressed hands, as the injuries were too many and too deep.

— Lonely, homesick, waiting in a cold line outside a phone tent to call my family at Christmas, my dear wife and children cry when they answer but then regain their composure, bravely supporting their man and supporting the mission as much as if they were Alpha Company, themselves.

It was good medicine in bad places. It was hard times. It mattered to all of us. It affected all of us.

I don’t have a lot of instinct but it was instinct that started me on writing this, after the combat tour was done and we got home and celebrated and normal life resumed and I could not exactly return to whom I was before I left. There were good parts to that arrangement such as every moment with Megan, the girls, family and friends feeling more precious than before, but there were unsettling parts as well because I could not find that same person who used to be me — like when you’re looking for something that you know you left safely behind but unfortunately now it’s nowhere to be found and you get on with things, thinking it will turn up sooner or later but it doesn’t… or maybe, maybe it was a feeling of alienation like some of the parts of that guy you used to know had gotten left behind in the desert, and the missing parts got replaced with other ones which weren’t exactly compatible and now you’re not sure what’s the right you and what is wrong. So, despite getting back to my normal routine and intensely loving those whom I loved there remained an unease and confusion deep inside and I could tell, I could just tell that it was something I should not trust to be left alone.

I had to process what I had seen and what we had done. I had expected that the war would be just one more thing in my life because I had in fact been building my way up to it for so long. But it turned out, for me at least, that despite all that preparation it was not just one more thing. It wasn’t the injuries or the surgeries that were necessarily the problem, it was the entirety of the situation that so affected and took me over. It was living inside the other aspect of things — the violent aspect. It was the vacuum of being there. It was the cost of visiting the Underworld.

Some elements of the war were more incomparable than others: the injured Marines, Soldiers, allies, enemies, villagers, and children; a geographic isolation matched only by the emotional distance we had to maintain from the surrounding events; the sadness and camaraderie mixed together in a daily draught from which we drank; the shock of battle and the sense of mission; the investment, the great, big, lifetime investment that we all made into this God-forsaken effort, and that investment’s convoluted sense of loss and reward.

At some point after I returned from it and once I was home and safe and snug, my wife Megan and our kids ran about their busy days and I had my regular-life stacking up on the desk but instead of getting immersed into normality… clack, clack, clack… I typed away like a madman, writing out these memories over and over, searching for meaning, capturing them in print, as if then I could work with them rather than be worked by them. And if I arranged and rearranged those little words in just the right way, I presumed and I hoped, maybe they would spell out the route for me to find my way back? The secret of life is in art [Oscar Wilde] and now I get that: if you want your life to make sense you’ve got to take it apart and break its events into pieces and sew or paste them back together in some way, shape, or form, so that the pattern they create makes sense. The artistic temperament can be a curse but like anything it can have its plusses, too. It helps you confront your goblins. And after going through this particular exercise, now I think everyone should write their own story, paint their picture, sing their song, if only to examine their life’s details and create a logical storyline out of them. It may not even be an absolutely true storyline but who really cares? What is true, anyway? I don’t remember.

My conscious intent in writing this narrative was to commemorate the whole experience before I forgot the details: the amazing, incredible teamwork of the US and NATO medical forces; the pronounced bravery and graciousness of the troops — troops concerned mostly about their company-mates even during those first agonizing moments after they were rendered minus a hand, or a foot, or a hand and a foot, or had to go to sleep so we could open their bodies to address more broken things inside there; I wished to commemorate our Alpha Surgical Company, whom I think of daily; and to commemorate the raw suffering of our servicemen, of our allies, of the Afghanis, even that of our enemies. These must be recorded for society to have and to remember.

Another intent was for this book to serve as a resource for the medical-types who follow us, for those unusual people entering into this sort of work. In preparing for my own career I read as many memoirs of military doctors and medical professionals as I did of Soldiers and Marines and Special Forces (although the medical memoirs are harder to find). And just as a person’s body would not transition from ordinary exercise to marathon running in a single day — well in 460 B.C. the first guy did, Pheidippides, and he died for it — similarly, a doctor or nurse or medic should not transition from ordinary life into combat life without some course of mental preparation. It is a whole step apart from an urban trauma center.

There is one final reason I kept these notes and wrote this account which is that serving as Medical brings its own perspective on war which is worth trying to capture, and which ought to be included in the complete narrative if the general public is going to understand what they’ve done by sending their men and women into combat. It is a narrowly defined perspective and to get it a person has to be in the medical field, must be in the military during a time of war, and get deployed to an area of it that sees actual fighting. This represents a small fraction of the military and a far smaller fraction of a nation’s population. But that small fraction’s experience has big implications because for them the horror is not yet sanitized, the combatants may not be in safe places, the bleeding is not yet stanched, the wounds aren’t bandaged, and unless the casualties are in shock or already dead they may still be screaming.

Because this is a war memoir and I am a surgeon I do not know what it was like out in the battle spaces hunting down the enemy, dodging IED’s, making split-second shoot or hold fire decisions, or facing down bullets cracking toward my skull; but I do know better than most what our people and their people suffered as a result of such things and I have seen enough of Death to hold him in respect.

In Flanders Fields

In Flanders fields the poppies blow

Between the crosses, row on row,

That mark our place; and in the sky

The larks, still bravely singing, fly

Scarce heard amid the guns below.

We are the Dead. Short days ago

We lived, felt dawn, saw sunset glow,

Loved, and were loved, and now we lie

In Flanders fields.

Take up our quarrel with the foe:

To you from failing hands we throw

The torch; be yours to hold it high.

If ye break faith with us who die

We shall not sleep, though poppies grow

In Flanders fields.

~John McCrae, 1915

If you are medical I think that Death is not your enemy, Death is your competition; and Death, I can tell you, Death wins at times.

Chapter Two:

Preparations

July, 1992, Rush Medical College, Chicago Illinois

No sooner had I started medical school in July of 1990 than did the U.S. invade Kuwait, initiating the Persian Gulf War. In the midst of the academic stresses I had to wonder whether I’d be called out of my studies to support the effort. I reassured myself that at this point I was so untrained I could be of no use to anybody, but unfortunately, or so it seemed, it also struck me that I had signed up to go. There was a strained moment of honest clarity when I realized that I didn’t wish to leave medical school to participate in a war, and yet here I’d gone and joined the Navy. It was a rather obvious and awkward predicament, to say the least.

In taking a commission I’d indulged in the usual youthful fantasies but above all else a sentiment that I wanted to walk a mile in my father’s moccasins. Now, reading and following the Persian Gulf War news reports with an owner’s eye, I was beginning to understand what walking in those moccasins might entail. As it turned out the Navy never called me for the Persian Gulf War, and those moccasins did not get activated; they did not get activated yet, at least.

The first two years of medical school happen in classrooms and laboratories. The second two occur within the hospital, and in those what you do is rotate from one clinical service to the next to the next.

I entered medical school expressly to become a psychiatrist, a Navy psychiatrist like my father had been. Thus, in my third year during my first clinical rotation it was with considerable surprise that I discovered if there was one thing I was pretty sure I wasn’t going to become, it was a psychiatrist.

Mom, it’s Paul. I can’t go into Psychiatry.

You can’t? she asked.

I don’t know why, but I just cannot do it. It’s not for me.

Oh your father would be so relieved! Mom said.

I plowed through Internal Medicine, Pediatrics, Neurology and several others, seeking in each of them a potential future self but never finding one, and it was finally my first day on Surgery service. Although I still did not know what specialty I would pursue I was a bit excited to see what the fuss was about, however it’s worth repeating that I was not banking on Surgery for a career, not one bit. In fact that’s why I scheduled it near the end of the third academic year rather than at the start of it.

The operating room staff and I were in our green cotton scrubs with blue sterile gowns worn over them. I was the sole student for the room. Dr. Doolas made a skin incision in the 52-year old male who was anesthetized and stretched out on the table. The scalpel cut a thin red line through the man’s skin, parallel to and just below the rib cage in the right upper quadrant of the abdominal wall. The doctor divided the soft tissues underneath with an electric cautery stick, creating a large opening into the patient’s abdominal cavity. As the cautery blazed through the muscle fibers of the man’s abdominal wall I was initially surprised and subsequently nauseated by the distinctive smell of meat cooking. I watched with what was probably a typical mix of fascination and fear that might possess any person directly observing a doctor stick their hand and wrist through a fresh, neat hole cut into somebody’s belly. Our transgressing inside this man was a fundamental breach, trespassing into a place we humans were never meant to be, and my instinctive response was that we’d better get out of there before we got caught!

That muscular arm of Dr. Doolas mucked around inside of the other human’s abdominal cavity for a minute or two until he pulled his hand back out and used it to grab my wrist.

Kid, put your mitt in here. That’s cancer. You’ll never forget it.

Despite my instinctive recoil he stuffed my hand into that hole in that guy’s belly. The abdominal tissues enveloping my fingers and wrist were wet, smooth, and warm; in a way it was like getting dunked in a swimming pool. At first I didn’t know what I was looking for in there and was only terrified I might blunder and cause a hemorrhage, or clumsily stick my fingers through a loop of intestine, or accidentally rip (avulse) the gallbladder off of the liver. Meanwhile the people in the room waited and watched as if they expected me to pull out a rabbit. So I collected myself and resolved to do what I was supposed to do. Conscious of their attention and of my mission I began to feel around gingerly, in my mind conjuring up pictures from anatomy books and trying to match them to what my sense of touch encountered. Stomach, intestine, and gallbladder: these were soft and indistinct and for the moment I couldn’t be certain which thing was which. The liver I knew to be a solid organ; my fingertips found its edge and then I advanced my hand further into the hole as I had