Special Report Anesthesia in the Desert: Experiences with the U.S. Marines during the Persian Gulf Conflict
Edward K. Heres, MD,* Richard G. Hetherington, DO* Department
of Anesthesia,
Introduction The Marine fighting soldier’s medical care is provided by the Navy. During the Desert Storm conflict this past year, Navy physicians were deployed with the Marines in the Persian Gulf both at sea and on the ground. Physicians of all specialties, notably general and orthopedic surgeons and anesthesiologists, were mobilized from both military and civilian practices. The Second Marine Division was supported by a medical battalion that was augmented from 300 to more than 1,000 health care providers during the months preceding Desert Storm. Never before had such a rapid expansion of U.S. military forces occurred. During the Vietnam War, the augmentation was gradual and took several years. During Desert Storm, once assigned or activated, physicians were assembled at Camp Lejeune, North Carolina, and Camp Pendleton, California, for 2 weeks of orientation to Marine operational medicine prior to transport to the war zone. The Marines had planned for physicians to staff three echelons of battlefield care: battalion aid stations (BASS), collecting and clearing companies (C&Cs), and surgical support teams (SSTs).
*Lieutenant Commander, Medical Corps, United States Naval serve; Staff Anesthesiologist
Re-
Address reprint requests to Dr. Heres at the Department of Anesthesia, National Naval Medical Center, Bethesda, MD 20889-5000, USA. The views expressed in this article are those of the authors and do not reflect the official policy of the Department of the Navy, the Department of Defense, or the United States Government. Received for publication October 10, 199 1; revised manuscript accepted for publication April 29, 1992. 0 1992 Butterworth-Heinemann J. Clin. Anesth. 4351-354,
19%.
National
Naval Medical Center,
Bethesda,
MD.
BASS, which were staffed with 2 physicians and 20 corpsmen (nursing assistants), were mobile and traveled with the lighting Marine units. They were charged with initial triage, airway management, and resuscitation of the battlefield casualties before transfer to a larger facility. The second echelon of care, the C&Cs, were set 5 to 10 miles from the front lines of combat. These were staffed with 8 physicians (2 general surgeons, 2 orthopedic surgeons, 2 anesthesiologists, and 2 internists), 2 nurses, and 80 corpsmen. The C&Cs had two operating rooms (ORs) and were equipped for additional resuscitation and some definitive care (surgical explorations to control hemorrhage, stabilization of fractures, and amputations). Patients were then evacuated to an SST or fleet hospital. The third echelon of battlefield care were the SSTs, which were manned with 15 physicians (4 general surgeons, 4 orthopedic surgeons, 4 anesthesiologists, and 3 internists), 8 nurses, and 100 corpsmen. The SSTs were positioned approximately 30 miles behind the C%Cs and had 5 ORs and 150 hospital beds. The SSTs provided care for overflow casualties from the C&Cs, as well as more definitive treatment of the resuscitated patients. Preparation and Organization Soon after assignment to the Marine bases, the medical battalion was divided into different-size companies according to echelon of care. This early division of personnel facilitated company organization and morale. The groups attended classes taught by Marine specialists in preventive medicine and military law of war. The preventive medicine classes described insect and environmental hazards indigenous to the deserts of Southwest Asia. The military law courses reviewed the rules of the Geneva Convention. There were also classes in Iraqi chemical and biological warfare. The chemical agents discussed included J. Clin. Anesth.,
vol. 4, September/October
1992
351
Special
Report
nerve gas (anticholinesterase) and mustard gas (blistering agent). The battalion was issued mission-oriented protective posture (MOPP) chemical protective gear and carbon-filtered gas masks, then practiced using the masks in tear gas chambers. Portable kits containing chemically treated wipes to remove the mustard agents also were issued. Atropine, pralidoxime, and diazepam autoinjectors were provided to personnel for emergency battlefield treatment of nerve gas poisoning. The biologic agents discussed were anthrax and botulism. Once in the combat zone, all troops were instructed to take ciproflaxacin (1,000 mg/d) for anthrax prophylaxis. All physicians were issued the same field equipment as the Marine infantrymen, including backpacks, individual tents, bulletproof flak jackets, helmets, and survival knives. Each battalion member also was issued a 9mm handgun and underwent a l-day training session on its proper use.
In Country After 2 weeks of training at the Marine bases, the battalion was flown to the port city of Al Jubail, Saudi Arabia, located approximately 120 miles from the Kuwaiti border. The group was housed in a trailer camp formerly occupied by oil refinery laborers. During the next 4 weeks, equipment issue and supply inventory continued, and each company established medical department heads. Physicians and administrative personnel attended intelligence meetings for information about the Iraqi armamentarium and chemical and biologic weaponry. During this time in Al Jubail, Navy anesthesiologists stationed at the nearby fleet hospital sponsored an all-day professional conference with speakers on anesthesia in austere conditions, specialized field anesthesia machines, battlefield regional anesthesia techniques, and combat blood banking.’ This time also was used for designing the layout of each company’s hospital in the desert. Marine tactical experts worked with company leaders and medical department heads to plan the safest and most efficient location for all patient areas and personnel berthing tents. Advance parties were sent north along the Kuwaiti border to pinpoint locations for each echelon of care.
Assembly of the Hospitals After 4 weeks in Al Jubail and once training was completed, all companies traveled to their designated locations in northern Saudi Arabia. One company was transported by bus 4 hours north to the site of a planned SST near Al Kabrit, a small Saudi town about 25 miles south of the Kuwaiti border and 20 miles west of the Persian Gulf. All the equipment for the SST was transported on 21 flatbed trailers. During the next 10 days, the company members, including physicians, built the hospital. The entire compound occupied a desolate 25acre area of desert and was surrounded by an %foothigh sand berm (Figure I). All hospital spaces and personnel berthing areas were located 6 feet below ground level in holes dug out by bulldozers supplied by the en352
J. Clin. Anesth., vol. 4, September/October
1992
ml
Communtcations
Figure 1. Layout of a surgical support team. RR1 covery room; OR = operating room.
= r-e-
gineering battalion. The “main street” of an SST consisted of a long corridor of tents and shelters that housed the triage area, the resuscitation (emergency) section, x ray, the preop area, five ORs, and the recovery room (Figure 2). The ORs were located in Marine Corps Expeditionary Shelter Systems, portable boxcar-like containers) that were transported to the camp by helicopter. Each 20- by B- by g-foot container housed 2 OR beds. Monitoring equipment located at each OR bed included an Ohio 401 oxygen analyzer (Ohmeda, Madison, WI), a HewlettPackard electrocardiogram (ECG)/defibrillator (HewlettPackard, Hayward, CA), a manual blood pressure (BP) cuff, and an Ohmeda 5120 pulse oximeter. The anesthesia machine was an Ohio 885 field machine (Ohmeda) equipped with a circle system, nitrous oxide (N,O) flowmeter, and measured-flow multiagent vaporizer. There were a small number of Autovent 2000 ventilators (Puritan-Bennett, Kansas City, KS). Airway equipment included masks, laryngoscopes, oral airways, and endotracheal tubes. A portable electric Sorenson suction apparatus (Abbott Medical, Abbott Park, IL) was at each bedside. There was no capacity for end-tidal partial pressure of carbon dioxide (PET.COP) measurement, invasive BP monitoring, or temperature measurement.
Anesthesia
Op-mting 3an*4
L
Rooms
with the U.S. Marks
during Desert Storm: HWS and Hetherington
units and other c:ompany hospitals. A decontamination chamber was created. The chamber had an overhead shower system and would be manned by designated corpsmen in MOPP gear who would scrub down victims of chemical warfare before they were transported to the triage area. Once the hospital was completed, mock masscasualty drills were performed, with an emphasis on triage management and patient transportation. A rotating physician call schedule, with daily trauma teams consisting of a general surgeon, an orthopedic surgeon, and an anesthesiologist, was announced. The allied air assault continued, with numerous nighttime alerts requiring all company members to don their MOPP gear and take temporary refuge in the bomb shelters. Before the ground war started, the hospital treated minor injuries and friendly fire accidents. Some patients with serious nonacute illnesses were transported by helicopter back to Al .Jubail fleet hospital.
The Ground War
Emergency
I-I Triage
Figure 2. “Main street” of a surgical support team, consisting of a long corridor of tents that housed the triage area, the resuscitation (emergency) section, x ray, the preop area, five operating rooms, and the recovery room. A storage area constructed within the OR suite housed anesthetic drugs and additional equipment. The anesthetic drug supply included thiopental sodium, ketamine, d-tubocurarine, succinylcholine, vecuronium, neostigmine, glycopyrrolate, and most local anesthetics. Volatile drugs included isoflurane and halothane, but not N,O. Spinal anesthesia kits and equipment (syringes, extension tubing, and beveled needles) were available for regional blocks. Oxygen tanks and other equipment were resupplied to each hospital by a medical logistics battalion located nearby in Al Kabrit. A makeshift intensive care unitipostanesthesia care unit with 12 patients beds was adjacent to the OR, with an ECG machine and H-cylinder with oxygen (0,) at each bedside. Tents were set up for the laboratory and pharmacy. The patients (approximately 150-bed capacity for an SST) were housed in tents with hardwood floors, each holding 15 patients. All company personnel lived in tents located around the perimeter of the hospital. Each tent had its own adjacent dugout bomb shelter with sandbag-reinforced walls. A loudspeaker system and telephone connection was set up between the physicians’ tent, the triage area, and the ORs. Electricity was provided by four diesel-powered field generators. An airstrip and helicopter landing site were built, and a radio system was set up between the Marine front-line
The ground war started on February 24, and the C&Cs and SSTs immediately began receiving Marine casualties and injured Iraqi prisoners. Over the next 5 days, one C&C located just behind the front lines treated 188 casualties, 87 of which were combat related. Seventy-five patients were taken to surgery, 59 of whom required general anesthesia for treatment of gunshot wounds, multiple shrapnel wounds, burns, and amputations of upper and lower extremities. Sixteen of the casualties required monitoring and intravenous (IV) sedation for wound debridement and other minor Injuries. Patients arrived by helicopter or ambulance from the field or a BAS and were triaged according to severity of injury. Stabilization and initial treatment consisted of IV hydration with a balanced crystalloid solution, broad-spectrum antibiotics, and pain control with IV morphine sulfate. If a patient required surgery, necessary radiographs and a hematocrit (Hct) were obtained. Once the patient was hemodynamically stable, he was taken to the OR. Most patients with devitalized extremities requiring amputations presented with an Hct in the 12% to 16% range. They were typed and crossed for 4 units of whole blood. The blood supply was “walking donor blood” drawn directly from company personnel and surrounding Marine units. After transfusions of‘ whole blood to an approximate Hct of 23% to 25%, general anesthesia was induced with thiopental sodium or ketamine and succinylcholine in rapid sequence while cricoid pressure was maintained. Anesthesia was maintained with a 5050 air-O, mixture and isoflurane or halothane. Spontaneous respirations were permitted in each patient because there were no OR ventilators and only manual BP cuffs. This technique freed the anesthesiologist’s hands to administer blood products and IV drugs. Morphine sulfate IV was titrated according to respiratory rate, and patients were extubated when awake. Monitoring consisted of ECG leads, manual BP cuff, precordial stethoscope, and pulse oximeter. Vecuronium was used for J. Clin. Anesth..
vol. 4, September/October
1992
353
Special
Report
some of the longer procedures, and the patient was manually ventilated. Under general anesthesia, many of the Iraqi soldiers had copious amounts of dark, thick secretions after intubation, which required almost constant suctioning of the endotracheal tube and oropharynx. Many of these Iraqi soldiers had spent the previous 4 to 5 months in desert trenches. The windblown sand may have been an irritant to the tracheobronchial tree, accounting for the large volume of secretions. No problems, as demonstrated by continuous pulse oximetry, were encountered in oxygenating these patients. As expected, the debilitated Iraqi patients required small amounts of morphine to maintain anesthesia, generally less than 5 mg IV. Most of these patients were moderately dehydrated, but none appeared severely malnourished. Spinal anesthesia was used in hemodynamically stable patients for lower-extremity debridements and amputations. After the patient was prehydrated with 2 to 3 liters of crystalloid solution, tetracaine in 10% dextrose was injected intrathecally with the patient in the sitting position to provide a TIO block. The C&Cs had no postanesthesia care facilities. This required a rapid recovery from anesthesia, as these patients were transported to the rear within 2 to 3 hours after surgery. After stabilization, the Iraqi prisoners were transferred to a central medical facility for containment. The Marines were transferred to the Navy fleet hospitals in Al Jabail After the official cease-fire, most of the Marine desert medical facilities were disassembled, and the personnel and equipment were transported back to Al Jabail. A few small medical camps remained in the desert until all the Marine units had departed. During the war, no Marine facility was ever over-
354
J. Clin. Anesth.,
vol. 4, September/October
1992
whelmed with casualties, since the number of injured was much lower than expected. Most patients received prompt resuscitation and stabilization, if not definitive care. The entire operation provided a valuable experience for all physicians in casualty care, surgery and anesthesia in austere conditions, and tactical design of a field hospital. Most physicians were asked to evaluate the present Marine operational medical system and provide feedback for any potential improvements. Suggestions were made regarding greater consistency in equipment distribution; more extensive monitoring capability, including P&O, and intra-arterial monitoring; and altered medical specialty distribution within each echelon of care. Some of the participating physicians, including both active-duty physicians and reservists activated from civilian practice, had volunteered for deployment to the combat zone. Many felt that the experience provided an unusual opportunity for them to use their training to serve their country. Acknowledgments We wish to acknowledge Linda Jo Rice, MD, for her assistance in preparing this report. We also wish to thank Mary Peifer and Sarah Stoessel for their assistance in manuscript preparation.
References 1. Bacon GS, Rich ‘I‘, Long ML, Trentalange M: Anesthesia at sea: initial experience aboard the hospital ship USNS Comfort during the Iraqi Crisis. J Clin An&h 1991;3: 173-7. 2. Carnes RS, Buzzanell C, Vulgamore JM: The Navy goes ashore: the deployment of Fleet Hospital Five in Saudi Arabia. J Clin. Anesth 1991:3:5-10.
Edward K. Heres, MD,* Richard G. Hetherington, DO* Department
of Anesthesia,
Introduction The Marine fighting soldier’s medical care is provided by the Navy. During the Desert Storm conflict this past year, Navy physicians were deployed with the Marines in the Persian Gulf both at sea and on the ground. Physicians of all specialties, notably general and orthopedic surgeons and anesthesiologists, were mobilized from both military and civilian practices. The Second Marine Division was supported by a medical battalion that was augmented from 300 to more than 1,000 health care providers during the months preceding Desert Storm. Never before had such a rapid expansion of U.S. military forces occurred. During the Vietnam War, the augmentation was gradual and took several years. During Desert Storm, once assigned or activated, physicians were assembled at Camp Lejeune, North Carolina, and Camp Pendleton, California, for 2 weeks of orientation to Marine operational medicine prior to transport to the war zone. The Marines had planned for physicians to staff three echelons of battlefield care: battalion aid stations (BASS), collecting and clearing companies (C&Cs), and surgical support teams (SSTs).
*Lieutenant Commander, Medical Corps, United States Naval serve; Staff Anesthesiologist
Re-
Address reprint requests to Dr. Heres at the Department of Anesthesia, National Naval Medical Center, Bethesda, MD 20889-5000, USA. The views expressed in this article are those of the authors and do not reflect the official policy of the Department of the Navy, the Department of Defense, or the United States Government. Received for publication October 10, 199 1; revised manuscript accepted for publication April 29, 1992. 0 1992 Butterworth-Heinemann J. Clin. Anesth. 4351-354,
19%.
National
Naval Medical Center,
Bethesda,
MD.
BASS, which were staffed with 2 physicians and 20 corpsmen (nursing assistants), were mobile and traveled with the lighting Marine units. They were charged with initial triage, airway management, and resuscitation of the battlefield casualties before transfer to a larger facility. The second echelon of care, the C&Cs, were set 5 to 10 miles from the front lines of combat. These were staffed with 8 physicians (2 general surgeons, 2 orthopedic surgeons, 2 anesthesiologists, and 2 internists), 2 nurses, and 80 corpsmen. The C&Cs had two operating rooms (ORs) and were equipped for additional resuscitation and some definitive care (surgical explorations to control hemorrhage, stabilization of fractures, and amputations). Patients were then evacuated to an SST or fleet hospital. The third echelon of battlefield care were the SSTs, which were manned with 15 physicians (4 general surgeons, 4 orthopedic surgeons, 4 anesthesiologists, and 3 internists), 8 nurses, and 100 corpsmen. The SSTs were positioned approximately 30 miles behind the C%Cs and had 5 ORs and 150 hospital beds. The SSTs provided care for overflow casualties from the C&Cs, as well as more definitive treatment of the resuscitated patients. Preparation and Organization Soon after assignment to the Marine bases, the medical battalion was divided into different-size companies according to echelon of care. This early division of personnel facilitated company organization and morale. The groups attended classes taught by Marine specialists in preventive medicine and military law of war. The preventive medicine classes described insect and environmental hazards indigenous to the deserts of Southwest Asia. The military law courses reviewed the rules of the Geneva Convention. There were also classes in Iraqi chemical and biological warfare. The chemical agents discussed included J. Clin. Anesth.,
vol. 4, September/October
1992
351
Special
Report
nerve gas (anticholinesterase) and mustard gas (blistering agent). The battalion was issued mission-oriented protective posture (MOPP) chemical protective gear and carbon-filtered gas masks, then practiced using the masks in tear gas chambers. Portable kits containing chemically treated wipes to remove the mustard agents also were issued. Atropine, pralidoxime, and diazepam autoinjectors were provided to personnel for emergency battlefield treatment of nerve gas poisoning. The biologic agents discussed were anthrax and botulism. Once in the combat zone, all troops were instructed to take ciproflaxacin (1,000 mg/d) for anthrax prophylaxis. All physicians were issued the same field equipment as the Marine infantrymen, including backpacks, individual tents, bulletproof flak jackets, helmets, and survival knives. Each battalion member also was issued a 9mm handgun and underwent a l-day training session on its proper use.
In Country After 2 weeks of training at the Marine bases, the battalion was flown to the port city of Al Jubail, Saudi Arabia, located approximately 120 miles from the Kuwaiti border. The group was housed in a trailer camp formerly occupied by oil refinery laborers. During the next 4 weeks, equipment issue and supply inventory continued, and each company established medical department heads. Physicians and administrative personnel attended intelligence meetings for information about the Iraqi armamentarium and chemical and biologic weaponry. During this time in Al Jubail, Navy anesthesiologists stationed at the nearby fleet hospital sponsored an all-day professional conference with speakers on anesthesia in austere conditions, specialized field anesthesia machines, battlefield regional anesthesia techniques, and combat blood banking.’ This time also was used for designing the layout of each company’s hospital in the desert. Marine tactical experts worked with company leaders and medical department heads to plan the safest and most efficient location for all patient areas and personnel berthing tents. Advance parties were sent north along the Kuwaiti border to pinpoint locations for each echelon of care.
Assembly of the Hospitals After 4 weeks in Al Jubail and once training was completed, all companies traveled to their designated locations in northern Saudi Arabia. One company was transported by bus 4 hours north to the site of a planned SST near Al Kabrit, a small Saudi town about 25 miles south of the Kuwaiti border and 20 miles west of the Persian Gulf. All the equipment for the SST was transported on 21 flatbed trailers. During the next 10 days, the company members, including physicians, built the hospital. The entire compound occupied a desolate 25acre area of desert and was surrounded by an %foothigh sand berm (Figure I). All hospital spaces and personnel berthing areas were located 6 feet below ground level in holes dug out by bulldozers supplied by the en352
J. Clin. Anesth., vol. 4, September/October
1992
ml
Communtcations
Figure 1. Layout of a surgical support team. RR1 covery room; OR = operating room.
= r-e-
gineering battalion. The “main street” of an SST consisted of a long corridor of tents and shelters that housed the triage area, the resuscitation (emergency) section, x ray, the preop area, five ORs, and the recovery room (Figure 2). The ORs were located in Marine Corps Expeditionary Shelter Systems, portable boxcar-like containers) that were transported to the camp by helicopter. Each 20- by B- by g-foot container housed 2 OR beds. Monitoring equipment located at each OR bed included an Ohio 401 oxygen analyzer (Ohmeda, Madison, WI), a HewlettPackard electrocardiogram (ECG)/defibrillator (HewlettPackard, Hayward, CA), a manual blood pressure (BP) cuff, and an Ohmeda 5120 pulse oximeter. The anesthesia machine was an Ohio 885 field machine (Ohmeda) equipped with a circle system, nitrous oxide (N,O) flowmeter, and measured-flow multiagent vaporizer. There were a small number of Autovent 2000 ventilators (Puritan-Bennett, Kansas City, KS). Airway equipment included masks, laryngoscopes, oral airways, and endotracheal tubes. A portable electric Sorenson suction apparatus (Abbott Medical, Abbott Park, IL) was at each bedside. There was no capacity for end-tidal partial pressure of carbon dioxide (PET.COP) measurement, invasive BP monitoring, or temperature measurement.
Anesthesia
Op-mting 3an*4
L
Rooms
with the U.S. Marks
during Desert Storm: HWS and Hetherington
units and other c:ompany hospitals. A decontamination chamber was created. The chamber had an overhead shower system and would be manned by designated corpsmen in MOPP gear who would scrub down victims of chemical warfare before they were transported to the triage area. Once the hospital was completed, mock masscasualty drills were performed, with an emphasis on triage management and patient transportation. A rotating physician call schedule, with daily trauma teams consisting of a general surgeon, an orthopedic surgeon, and an anesthesiologist, was announced. The allied air assault continued, with numerous nighttime alerts requiring all company members to don their MOPP gear and take temporary refuge in the bomb shelters. Before the ground war started, the hospital treated minor injuries and friendly fire accidents. Some patients with serious nonacute illnesses were transported by helicopter back to Al .Jubail fleet hospital.
The Ground War
Emergency
I-I Triage
Figure 2. “Main street” of a surgical support team, consisting of a long corridor of tents that housed the triage area, the resuscitation (emergency) section, x ray, the preop area, five operating rooms, and the recovery room. A storage area constructed within the OR suite housed anesthetic drugs and additional equipment. The anesthetic drug supply included thiopental sodium, ketamine, d-tubocurarine, succinylcholine, vecuronium, neostigmine, glycopyrrolate, and most local anesthetics. Volatile drugs included isoflurane and halothane, but not N,O. Spinal anesthesia kits and equipment (syringes, extension tubing, and beveled needles) were available for regional blocks. Oxygen tanks and other equipment were resupplied to each hospital by a medical logistics battalion located nearby in Al Kabrit. A makeshift intensive care unitipostanesthesia care unit with 12 patients beds was adjacent to the OR, with an ECG machine and H-cylinder with oxygen (0,) at each bedside. Tents were set up for the laboratory and pharmacy. The patients (approximately 150-bed capacity for an SST) were housed in tents with hardwood floors, each holding 15 patients. All company personnel lived in tents located around the perimeter of the hospital. Each tent had its own adjacent dugout bomb shelter with sandbag-reinforced walls. A loudspeaker system and telephone connection was set up between the physicians’ tent, the triage area, and the ORs. Electricity was provided by four diesel-powered field generators. An airstrip and helicopter landing site were built, and a radio system was set up between the Marine front-line
The ground war started on February 24, and the C&Cs and SSTs immediately began receiving Marine casualties and injured Iraqi prisoners. Over the next 5 days, one C&C located just behind the front lines treated 188 casualties, 87 of which were combat related. Seventy-five patients were taken to surgery, 59 of whom required general anesthesia for treatment of gunshot wounds, multiple shrapnel wounds, burns, and amputations of upper and lower extremities. Sixteen of the casualties required monitoring and intravenous (IV) sedation for wound debridement and other minor Injuries. Patients arrived by helicopter or ambulance from the field or a BAS and were triaged according to severity of injury. Stabilization and initial treatment consisted of IV hydration with a balanced crystalloid solution, broad-spectrum antibiotics, and pain control with IV morphine sulfate. If a patient required surgery, necessary radiographs and a hematocrit (Hct) were obtained. Once the patient was hemodynamically stable, he was taken to the OR. Most patients with devitalized extremities requiring amputations presented with an Hct in the 12% to 16% range. They were typed and crossed for 4 units of whole blood. The blood supply was “walking donor blood” drawn directly from company personnel and surrounding Marine units. After transfusions of‘ whole blood to an approximate Hct of 23% to 25%, general anesthesia was induced with thiopental sodium or ketamine and succinylcholine in rapid sequence while cricoid pressure was maintained. Anesthesia was maintained with a 5050 air-O, mixture and isoflurane or halothane. Spontaneous respirations were permitted in each patient because there were no OR ventilators and only manual BP cuffs. This technique freed the anesthesiologist’s hands to administer blood products and IV drugs. Morphine sulfate IV was titrated according to respiratory rate, and patients were extubated when awake. Monitoring consisted of ECG leads, manual BP cuff, precordial stethoscope, and pulse oximeter. Vecuronium was used for J. Clin. Anesth..
vol. 4, September/October
1992
353
Special
Report
some of the longer procedures, and the patient was manually ventilated. Under general anesthesia, many of the Iraqi soldiers had copious amounts of dark, thick secretions after intubation, which required almost constant suctioning of the endotracheal tube and oropharynx. Many of these Iraqi soldiers had spent the previous 4 to 5 months in desert trenches. The windblown sand may have been an irritant to the tracheobronchial tree, accounting for the large volume of secretions. No problems, as demonstrated by continuous pulse oximetry, were encountered in oxygenating these patients. As expected, the debilitated Iraqi patients required small amounts of morphine to maintain anesthesia, generally less than 5 mg IV. Most of these patients were moderately dehydrated, but none appeared severely malnourished. Spinal anesthesia was used in hemodynamically stable patients for lower-extremity debridements and amputations. After the patient was prehydrated with 2 to 3 liters of crystalloid solution, tetracaine in 10% dextrose was injected intrathecally with the patient in the sitting position to provide a TIO block. The C&Cs had no postanesthesia care facilities. This required a rapid recovery from anesthesia, as these patients were transported to the rear within 2 to 3 hours after surgery. After stabilization, the Iraqi prisoners were transferred to a central medical facility for containment. The Marines were transferred to the Navy fleet hospitals in Al Jabail After the official cease-fire, most of the Marine desert medical facilities were disassembled, and the personnel and equipment were transported back to Al Jabail. A few small medical camps remained in the desert until all the Marine units had departed. During the war, no Marine facility was ever over-
354
J. Clin. Anesth.,
vol. 4, September/October
1992
whelmed with casualties, since the number of injured was much lower than expected. Most patients received prompt resuscitation and stabilization, if not definitive care. The entire operation provided a valuable experience for all physicians in casualty care, surgery and anesthesia in austere conditions, and tactical design of a field hospital. Most physicians were asked to evaluate the present Marine operational medical system and provide feedback for any potential improvements. Suggestions were made regarding greater consistency in equipment distribution; more extensive monitoring capability, including P&O, and intra-arterial monitoring; and altered medical specialty distribution within each echelon of care. Some of the participating physicians, including both active-duty physicians and reservists activated from civilian practice, had volunteered for deployment to the combat zone. Many felt that the experience provided an unusual opportunity for them to use their training to serve their country. Acknowledgments We wish to acknowledge Linda Jo Rice, MD, for her assistance in preparing this report. We also wish to thank Mary Peifer and Sarah Stoessel for their assistance in manuscript preparation.
References 1. Bacon GS, Rich ‘I‘, Long ML, Trentalange M: Anesthesia at sea: initial experience aboard the hospital ship USNS Comfort during the Iraqi Crisis. J Clin An&h 1991;3: 173-7. 2. Carnes RS, Buzzanell C, Vulgamore JM: The Navy goes ashore: the deployment of Fleet Hospital Five in Saudi Arabia. J Clin. Anesth 1991:3:5-10.
