By: Norman Bauman for Wounds1
In February 2003, Captain Stephen F. McCartney, M.D., United States Navy, arrived at Logistical Support Area Coyote, on the Iraq-Kuwaiti border, to wait for the U.S. attack on Iraq. The 54-year-old grandfather had been trained and issued a 9mm Beretta side arm, flak jacket, Kevlar helmet and survival equipment called “782 gear”. Dr. McCartney was a surgeon, preparing to treat the injured American forces – as well as the injured enemy prisoners and civilians.
Dr. McCartney was chief of medical staff of the "far forward" Alpha Surgical Company, 1st Health Services Battalion, part of the First Marine Expeditionary Force from Camp Pendleton, San Diego. "It's gratifying to serve your country when they need you most," he said.
"Our job was to train and organize a combat surgical hospital in anticipation of immense casualties when the war began March 20," Dr. McCartney recalled at the 2006 VEITHsymposium™ in New York on November 18.
Dr. McCartney was in charge of 20 doctors, 34 nurses, and 121 other health care professionals. "Our entire hospital was 14 canvas tents," which contained three operating rooms, a portable X-ray facility, a mobile lab, and a 60-bed ward.
"We had 24 mass casualty drills in anticipation," said Dr. McCartney. "We had a disparate group of people from all over the Navy come together," so they had to train together. They did 25 surgeries and cared for several hundred patients before the war began, including appendectomies, errant gunshot wounds, broken bones, and infected tonsils. "We actually worked the system a bit before the war even started."
One of the lessons learned was the importance of training. "We need to train as a team before the war, not when it's getting ready to start," said Dr. McCartney. "Few, if any of us had ever been in a combat environment," said Dr. McCartney.
The war started for Alpha Surgical March 20. For 10 days, "we got all the Marine casualties that went into Nasiriya and the Rumallah oil fields," said Dr. McCartney. CH-46 helicopters as well as C-130 aircraft arrived with the many wounded. "There was a flood of patients," said Dr. McCartney. "It was mostly blast, grenade and mortar injuries, gunshot wounds, and burns."
The casualties were 90 percent Marines and 10 percent Army, said Dr. McCartney. "Marines" includes sailors. The Navy Fleet Marine corpsmen serve in battle with the Marines. A Marine would be injured and yell, "Doc, or corpsman up." The Navy Corpsman would run "right into harm's way," he said. "We got them in these patterns," said Dr. McCartney. "Two Marines and one corpsman; one Marine, one corpsman." Many corpsmen were injured coming to the aid of their bleeding Marines.
A typical case would be "terrible explosive injuries to lower extremities" from land mines or grenades, said Dr. McCartney. A mine injury produces "devastating loss of muscle and skin, with gross deformity and fractures," said Dr. McCartney. The leg would oftentimes be lost from the knee down.
When treating these wounds, the first concern is stopping the bleeding, replacing the blood loss and avoiding hypothermia, said Dr. McCartney. Then they had to decide whether they could save the limb. "I had a rule," said Dr. McCartney. "Two surgeons had to agree that amputation was the best route. Being a vascular surgeon, I could usually know if a limb was viable, but I would have an orthopedic surgeon who would have to agree. If not, if there was any chance to restore the limb or salvage it, we would move ahead.
"We had to make a quick decision in a tent," said Dr. McCartney, "Is this leg salvageable? Is it reasonable that somewhere at Walter Reed or Bethesda four months from now, could he possibly be walking, with the best of care? If we decided there was potential, we wouldn't amputate. We would just stop the bleeding and medevac him out to the next higher level of care. But if we could tell at that time there was nothing viable, we would do the amputation there, right there in the desert."
Often the decision was obvious. There was nothing there. "There would be tremendous soft tissue damage from the thigh down to the ankle," said Dr. McCartney. "It looked as if you had picked a chicken bone clean.
"I've followed up with some of the vascular patients and they've all done well without further complications, mainly because they're young and healthy to begin with," said Dr. McCartney. "They've got great attitudes, they want to get out of the hospital and run a marathon," he said. "They're Marines with unbelievably positive attitudes."
Many Marines do run in the Marine Corps Marathon, in wheelchairs and on prosthetic limbs. "Some of them still parachute with one leg missing," said Dr. McCartney.
The new prosthetic legs are energy efficient and "much, much" better, said Dr. McCartney. "They're titanium, they weigh about 24 ounces."
Marines with a limb amputation many times get a medical discharge, but if they want to stay, "the military does the best it can to keep them in," said Dr. McCartney. "These guys have a lot to offer, they're motivated, they've got tremendous combat experience and skills. They still want to serve and be around fellow Marines. It would be wasteful to give them a monthly check and send them out."
After 10 days, the American forces secured the highways, and inserted Bravo and Charlie Surgical Companies. "I quit doing direct patient care," said Dr. McCartney. He stayed in Iraq until July 2003, evaluating surgical capabilities in Iraq, like a forward-deployed eight-man surgical hospital, with two surgeons and an anesthesiologist half a kilometer behind the battle.
They developed modular, "snap-together" hospitals to replace the older canvas tents. "That came directly out of our lessons learned out there in the desert over some cold Coke and MREs [meals-ready-to-eat, or affectionately named ‘meals refusing to exit’]", said Dr. McCartney. These innovations made previously uniformly fatal injuries potentially survivable.
Dr. McCartney and Alpha Surgical Company also treated Iraqi civilian casualties. "I got involved with some heart-breaking Iraqi cases," said Dr. McCartney. "The Iraqi kids would bring home hand grenades or munitions - they weren't necessarily ours - they would accidentally blow up their whole family."
"Then there were the friendly fire incidents," said Dr. McCartney. A 12-year-old boy, the son of a date farmer, was hit with errant fire from an A-10 “Warthog” attack. A 20-millimeter cannon shell went through his leg, his abdomen and out his arm. The boy was cared for initially at Alpha Surgical then medevaced to the 47th Army Surgical Hospital in Kuwait City. After several operations and excellent care from Army medical staff, he survived and returned to his home near Baghdad.
Special operations medical support
Dr. McCartney is now Command Surgeon for the Marine Corps Forces Special Operations Command (MARSOC), Camp LeJeune, N.C. He is responsible for the medical support given to USMC Special Operations Forces.
His MARSOC Medical Department is building up the medical support structure for MARSOC. "It's exciting to build an organization from the ground up," said Dr. McCartney. Special operations are mostly clandestine and classified. According to published accounts, special forces crossed into Iraq before the start of the war to guide strike aircraft. These missions need specialized medical support, someone to take care of a wide array of injuries in many different enviroments.
"MARSOC Medical provides, trains, equips and organizes specially-trained Navy Special Operations medics, to support a wide variety missions in the Global War on Terror," said Dr. McCartney. These Special Amphibious Reconnaissance Corpsmen (SARC) get a year and a half of special training. They have to do everything medical, from a rash or infection to a life and limb threatening combat injuries,” said Dr. McCartney.
In special operations, you may not be able to evacuate the injured in 30 minutes. It might be 3 days "so these corpsmen have to know a lot more," said Dr. McCartney. "You have to know how to care for the badly injured and not have that luxury to pass the Marine off to another facility. You may be on a cliff in a far away country.”
"They have the most advanced lifesaving technology that they can carry in a 60-pound rucksack on their back," said Dr. McCartney. They have hemostatic dressings which are unavailable in private practice, that can stop major bleeding in minutes. More important, they have tremendous judgment and clinical skills.
In special operations the goal is mission success, not towards " medevac and go home," said Dr. McCartney "If a Marine takes two bullets in the thigh, the corpsman’s goals are to make it where he can go back and keep putting rounds on target, otherwise the whole team may perish.”
A military medicine career
"Navy medicine offers the surgeon a wide-open highway for leadership, for personal growth, and pride that I don't think can be gained anywhere else," said Dr. McCartney. "I'm extremely proud to serve my country and especially with the Marines."
Dr. McCartney trained in general surgery at Harbor UCLA Medical Center, Torrance, California. "I joined the Navy initially for two years just for the experience," he said.
He was a general surgeon in Navy hospitals and also on aircraft carriers. The Navy sent him to McGill University, Montreal, to train in vascular surgery. He was later Chief, Vascular Surgery Division at Navy Medical Center, Oakland, California.
"I took an 11-year break and went into private practice to raise my kids and experience the challenges of being my own boss," said Dr. McCartney. "I enjoyed private practice but I did miss the Navy," said Dr. McCartney. "The easiest thing was operating on the patient." But he spent more than half his time running a business, when he would rather be thinking about the patient with the recent carotid artery operation, or aneurysm surgery recovering in the ICU.
Finally his kids grew up, so he said, "Let's go back to the Navy." His wife agreed. "It just happened to be 3 months before 9/11," said Dr. McCartney, "so somebody bigger than me was calling the shots."
"I work for a two-star general, and I'm in charge of all things medical for a 2,600-man Marine Corps Special Operations Command, MARSOC," said Dr. McCartney. The general may say, "Steve, we're going to send 40 guys into this place or that place." So, said Dr. McCartney, "It's my job to make sure that they've got the appropriate medical support tailored for that mission. My shop is in charge of all things medical, planning, operations, medical intelligence”.
"I do try to squeeze a few days a month to run a vascular clinic at our hospitals, and teach the young general surgeons vascular," said Dr. McCartney. He tries to build up the vascular surgery services wherever he goes. "I just spent three years in Okinawa, and I started up my own vascular clinic.
"General surgeons in the Navy tend to be young guys right out of training, so they like having an older guy around to help them out," said Dr. McCartney. Most are on scholarships, get their training in the Navy, and owe the Navy three or four years.
The war in Iraq is controversial. Some people wouldn't join the military because they don't agree with the mission. "Yep," acknowledges Dr. McCartney. "If you can't adapt to that, you'll always have problems in the military." But his colleagues run "the entire gamut of the political spectrum."
He compares military professionalism to medical professionalism. "We're professionals and all of this is outside of our realm," says Dr. McCartney. A doctor in an emergency room will "treat a prince or a beggar the same way." During the first 10 days, helicopters were bringing in wounded prisoners along with wounded Americans. One of Dr. McCartney's patients was from the feared and despicable Saddam Fedeyeen, "the worst of the worst," shot through the right eye. "He was alive. He had a significant head injury. We evaluated him, we took him to the ICU, stopped the bleeding, established an airway, put him on a ventilator, and gave him meds to keep his blood pressure stable." He died. "Had he survived longer, I would have shipped him to the Army Surgical Facility for more care”.
"I spoke to everybody long before the war started, and said this is how were going to do business with POW," said Dr. McCartney. "The minute they lose the ability to resist or cause harm, we're going to give them the best of care."
The Iraqis captured an American, PFC Jessica Lynch, and took her to an Iraqi hospital. "The Iraqi doctors cared for her legs," said Dr. McCartney. If you treat enemy prisoners poorly, "then you're going to expect to get treated poorly if you get captured."
As a surgeon, Dr. McCartney could go to Iran or Iraq, and meet surgical colleagues "who may very well have trained in London 20 years ago."
"I would be surprised if I wasn't treated respectfully by fellow surgeons," said Dr. McCartney. "I think that what we share as surgeons and professionals transcends a lot of cultural differences and politics. I feel there are good people everywhere.”