AMA House of Delegates

Making transition to combat zone can be surreal, AMA delegates learn

Doctors in Afghanistan and Iraq recall sand on operating tables and 20 trauma cases at a time, but also rewards along the way.

By Carolyne Krupa — Posted July 4, 2011

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As a surgeon treating military troops this spring in Iraq's Al Anbar province, Raj S. Ambay, MD, DDS, worked under extreme heat and treacherous weather.

During frequent sandstorms, the skies would turn an eerie orange before becoming pitch black for up to seven hours at a time, making it difficult to see even 20 feet.

Treating patients was difficult because a layer of dust-like sand settled over everything. "The sand was everywhere, even on the operating table," said Dr. Ambay, a major in the U.S. Army Reserve and a former member of the AMA's Board of Trustees. "So much of what we did was complicated by high infection rates."

Serving as a physician in a combat zone is harrowing yet rewarding, said Dr. Ambay and two other military physicians who spoke during a June 20 educational session at the AMA Annual Meeting.

Physicians must cope with being away from home and loved ones, treat devastating injuries unlike anything they see in the United States, and learn quickly to adapt to any situation, said Darin Via, MD, a Navy captain, anesthesiologist and deputy commander of the Naval Medical Center in Portsmouth, Va.

During his tour in Kandahar, Afghanistan, Dr. Via and fellow personnel kept morale high by focusing on their mission. "We were privileged to treat the most deserving patients in the world," he said.

"Here we go"

Andrew Muck, MD, an Air Force major and an emergency physician who served in Iraq and Afghanistan, said making the transition to a war zone is surreal.


Dr. Ambay

"One day you go to sleep, and somehow the next day you wake up and you are in a combat zone," he said.

As medical director of a hospital in Balad, Iraq, in 2008, Dr. Muck said sometimes doctors would get more than 20 trauma cases at once.

"You hear the thump, thump, thump of the helicopter and think, 'Here we go,' " said Dr. Muck, assistant program director of emergency medicine at San Antonio Uniformed Services Health Education Consortium.

"You never knew what was going to be pulled off of that helicopter."

Physicians have to be flexible and treat a variety of injuries. "Generalists have to be specialists, and specialists have to be generalists," Dr. Via said.

The most common injuries were from improvised explosive devices. Gunners exposed at the top of armored vehicles usually were killed instantly, and drivers often needed amputations after blasts tore their legs to shreds.

Dr. Ambay, a plastic surgeon at James A. Haley Veterans Hospital in Tampa, Fla., said he saw soldiers injured by IEDs that had been filled with pellets, glass and pieces of barbed wire.

The items had been dipped in rat poison, making it hard to control bleeding.

Working on a critical care air transport team in Afghanistan, Dr. Muck learned to treat patients in any aircraft available.

His team often found themselves in cramped conditions, under poor lighting and without heat. "We did great, high-level care in the dark and in the cold," he said.

Dr. Ambay, who spoke by phone from Kuwait, recalled meeting a Vietnam veteran when he first arrived in the Middle East who told him: "Serving in combat is a million-dollar experience that you wouldn't pay a million dollars to experience."

He laughed at the time. "I didn't know then how right he was. I had an experience that I am going to remember forever," he said.

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Meeting notes: Public health

Issue: Increased awareness by physicians and the public of sickle cell disease and its treatment is needed.

Proposed action: A Board of Trustees Report called on the AMA to recognize sickle cell disease as a chronic illness; to encourage educational efforts on treatment and prevention; and to support newborn screening programs, genetic counseling and new research designed to speed the clinical implementation of new treatment. [Adopted]

Issue: Exposure to potentially harmful levels of mercury is prevalent in the population and has been implicated in a variety of secondary health effects such as cardiovascular morbidity, leukemia and reproductive toxicity. Approximately 188 cement kilns emit more than 11,000 pounds of mercury each year.

Proposed action: Direct the AMA to support modern and strict monitoring of mercury emissions from cement plants. [Adopted]

Issue: The Centers for Disease Control and Prevention has reported an increase in bloodborne infection transmissions caused by the shared use of fingerstick and point-of-care blood testing devices.

Proposed action: Encourage improved labeling of devices to make clear that multiple-use fingerstick devices made for single patients are intended for use only on single patients. [Adopted]

Issue: Pills are not easily identifiable by patients or physicians, which has led to harmful and sometimes fatal outcomes.

Proposed action: Strongly recommend to drug manufacturers that they put a consumer-friendly, unique identifier on the solid dosage forms and recommend that publishers of medication lists include a list of the identifiers. [Adopted]

Issue: Advertisers often alter photographs to enhance the appearance of models' bodies. Such alterations can contribute to unrealistic expectations of appropriate body image, particularly among children and adolescents.

Proposed action: Urge advertising associations to work with organizations that focus on child and adolescent health to develop guidelines discouraging the altering of photographs in a manner that could promote unrealistic expectations of appropriate body image. The focus should be on ads that appear in teen-oriented publications. [Adopted]

Issue: Transgender patients commonly undergo hormone replacement therapy, during which they experience continuously elevated levels of testosterone, estrogen or other hormones over a period of months, years or even decades. Effects of short and medium terms of treatment have been studied, but the effects of long-term use are unknown.

Proposed action: Direct the AMA to encourage research into the impact of long-term administration of hormone replacement therapy in transgender patients. [Adopted]

Issue: At one year postpartum, almost 25% of women retained at least 10 pounds of the weight gained during pregnancy, according to a 2007 study. Additionally, more than half of all obstetrician-gynecologists surveyed considered their training on weight management to be "inadequate" or "nonexistent," said a 2006 report.

Proposed action: Encourage physician referrals of pregnant and recent postpartum patients for nutrition counseling. The policy also directs the AMA to advocate for the extension of health insurance coverage for nutrition counseling among such patients. [Adopted]

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