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Military Medicine in Iraq

 Doctors get a lot of flak these days without ever going near a battle zone. They are bombarded with accusations of not caring about their patients, of being shills for Big Pharma, of being motivated by money, of killing patients with medical errors and drug side effects. In addition, they are bombarded with claims that non-scientific medical systems (so-called alternative medicine, from chiropractic to Ayurveda) offer greater benefits to patients. 

It was a delight to read a new book   about a doctor who was exposed to real flak in Iraq. His story is a wonderful reminder of how effective modern medicine is and it is an eye-opener about the selfless dedication of doctors who put themselves in harm’s way; who accept lower incomes, separation from families, and poor living conditions; who care desperately about their patients; and who magnanimously apply the same skills to treating friend and foe. 

The title is Coppola: A Pediatric Surgeon in Iraq. The author, Chris Coppola, is an Air Force pediatric surgeon who was twice deployed to Balad Air Base, 50 miles north of Baghdad, as a trauma surgeon. In his first night on call, he treats the five worst gunshot injuries he has ever seen – and they are all in the same patient! Despite serious damage to liver, colon, small intestine, pancreas, duodenum, vena cava and spine, the patient, a 22 year old Iraqi policeman, recovers. As the foreword of the book explains, the survival rate for troops injured in the field was 20% in WWI, 40% in WWII, 66% in Viet Nam, and is now an astounding 97% in Iraq. Lessons learned in war are translated to civilian trauma care and we all benefit from the knowledge however much we may deplore the war. 

No subluxations were adjusted, no qi manipulated, no acupuncture points stimulated, no homeopathic or herbal medicines given. Beside numbers like these, alternative medicine looks pretty puny and irrelevant. And the Air Force’s initiative to train doctors in battlefield acupuncture looks frankly delusional. 

Coppola is in Iraq during the first elections. An elderly woman is the victim of an IED (Improvised Explosive Device) detonated near a line of people waiting to vote. As they prepare her for surgery to stabilize her broken bones, she proudly holds up her right index finger with the purple ink stain showing she voted. They also treat a 17 year old girl who was shot in the neck at a polling place and will likely never walk again. They treat a small child with a skull fractured by shrapnel while waiting with his father in a voting line. Children are particularly at risk from IEDs: their heads are proportionately larger and they are closer to the ground. 

They treat an insurgent whose bomb detonated prematurely. He is a would-be murderer, but all Coppola sees is “a dying man who needs our treatment.” 

He has to work through translators. Cultural differences intrude as he tries to explain to a father that his baby “boy” is really a girl with an intersex condition. Such a child would be raised as a girl in the US, but the Iraqi father violently objects to that option because of cultural prejudice against females. 

They treat many Iraqi citizens and are worried when they release them because they are not likely to get adequate follow-up care. The Iraqi medical system has been devastated: doctors have fled, supplies are impossible to get. The Iraqis are not taxed: the government is funded only by oil sales and foreign aid. They do colostomies meant to be temporary but know it is unlikely their patients will ever be able to get the colostomies taken down. They see Iraqis with soiled towels wrapped around their colostomies because they can’t get colostomy bags. When a colleague wonders if they should send a patient to a burn facility, he is told “We are the burn facility in Iraq.” 

The Iraqi children he treats are small for their age and malnourished. Nutritious food is part of the medical treatment. They discover that a Kurdish refugee boy is only taking a few bites of his meals and hoarding the rest to take home to his family. They persuade him to eat by offering him Oreos and enough other donations from their own care packages to fill two large bags to take home. 

Coppola paints a vivid picture of deployed life: eating MREs (Meals Ready to Eat), jogging with 35 pounds of body armor and other protective equipment, suffering through the “hurry up and wait” military hassles, having to wear a gun in the OR during alerts, taking cover from incoming missiles, desperately missing his family. There is a signpost with the distance to various cities around the world, topped by a sign “Hell – 0 miles.” And yet he is more than willing to go back for a second deployment because he knows how badly he is needed. 

He treats casualties from the battle at Abu Ghraib prison, where prisoners and insurgents mounted a coordinated attack on the guards. Iraqis tell him they were not surprised to learn that prisoners had been tortured by Americans. They assumed that torture was being used – torture had always been a part of that prison, and far worse had happened under Saddam Hussein, attested to by the adjacent mass graves. Not that that’s any excuse. 

By his second tour, the patient population had changed. After the troop surge, Al Qaeda was no longer so brave about attacking Americans; now they concentrated on civilian targets, even including schools. Instead of American and Iraqi soldiers, now most of their patients are civilians and 1/3 of them are children. 

One of the most affecting stories in the book is that of Leila, a little girl who was extensively burned by an incendiary bomb thrown into her home. Her father was an Iraqi officer who had been successfully subduing the insurgents in his area and this was an act of revenge. Coppola is doing a complicated skin graft procedure on Leila when an emergency intervenes to commandeer his OR; he has to improvise to save the grafts and free up the OR as soon as possible. He treats her tenderly for a couple of months and is devastated when she eventually dies of a complicating infection. Later an Iraqi adult patient is taken away by guards. Coppola learns that that patient was the one who had thrown the firebomb into Leila’s house – and the American hospital had saved his life. And he later learns that Leila’s father is killed by insurgents. 

Another detainee is ungrateful even after several life-saving operations. He only speaks to repeatedly vow to shoot them all. 

Coppola is in the OR during a Christmas USO show with Robin Williams, Lance Armstrong, Miss USA, Kid Rock, Lewis Black and other celebrities. He is sorry that he missed the concert but says he couldn’t have enjoyed it knowing a child was waiting to be operated on. He says, “Each new injured child I see seems to rip the scab off a wound in my heart that won’t let me rest.” One of the reasons he chose surgery over pediatrics is that he is so distressed when he has to cause pain to an awake child. 

Coppola accepted an Air Force scholarship and advanced training that obligated him to 6 years of pay-back service. He points out that this meant a financial disadvantage. In 3 years in private practice he could have paid off any medical school debts and still have had a greater income than his Air Force salary for 6 years. He joined the Air Force because he wanted to serve his country. He went to Iraq because he had signed a contract and was obligated to go wherever they sent him.  Some of his colleagues supported the war, some did not, but they were all there to save lives. All were volunteers. 

One word kept running through my mind as I read this book. It is a word seldom used these days. The word is “honor.”

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