Afghan Campaign 2001-

About: Afghan Campaign 2001- is a research topic. Over the lifetime, 79 publications have been published within this topic receiving 543 citations.

Caring for families with deployment stress.

Abstract: How nurses can make a difference in the lives of military families.

Strengthening Our Soldiers (SOS) and Their Families: Contemporary Psychological Advances Applied to Wartime Problems. Why Now? Why Us? What Next?

Abstract: Since October 2001, approximately 2 million U.S. troops have been deployed for Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) in Afghanistan and Iraq. Serving in military campaigns such as OEF/OIF provides service members with income to support themselves and their families, job skills, opportunities for physical fitness, health care, educational opportunities (especially in regards to cutting edge technology), and a support network. However, early evidence suggests that the psychological toll of these deployments—many involving prolonged exposure to combat-related stress over multiple rotations—may be disproportionately high compared with the physical injuries of combat (Tanielian et al., 2007). Between 11% and 42% of returning service members report some type of mental health problem during post-deployment screenings (Hoge et al., 2004; Milliken, Auchterlonie, & Hoge, 2007). Concerns have been most recently centered on two combat-related injuries in particular: post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI). In fact, many recent reports have referred to these as the signature wounds of the Afghanistan and Iraq conflicts and remarked that even more new cases will likely be identified over time (Milliken et al., 2007). The operational tempo associated with OEF/OIF in conjunction with extended and multiple deployments and shortened dwell time between deployments have placed unprecedented stress upon service members. Simultaneously, the survival rate of exceeds those of all previous wars (Lew et al., 2009). OEF/OIF war fighters have extreme physical demands placed on their bodies, including the need to move rapidly while carrying heavy loads over difficult terrain. They are engaged in and exposed to high stress conditions combined with sleeping on cots with little back support, standing on their feet for hours at a time, riding in convoys in crunched positions and wearing heavy body armor. All of these activities contribute to musculoskeletal problems, which are the number one cause of disability discharge from the military (USARIEM, 2006). The human stress response has a number of checks and balances to ensure that various components do not become hyperactive. Unfortunately, in the case of severe or chronic stress, these normal checks and balances can fail. When they do, humans become vulnerable to disease. This failure leads to a series of physiologic consequences, such as sleep disruptions; changes to brain structures, such as the hippocampus and prefrontal cortex; bone mineral loss; abdominal obesity; and increased risk of cardiovascular disease (McEwen, 2003). B. G. Melamed Former Director, Clinical Heath Psychology Postdoctoral Fellowship Program, Department of Psychology, Tripler Army Medical Center, Honolulu, HI 96859, USA e-mail: barbara@drmelamed.net

A piece of my mind. Sleepless.

Abstract: Sleepless I THOUGHT ABOUT OUR ENEMIES TONIGHT, AND WHY AND how we physicians care for them. It has been said that downed American pilots and other servicemen returning from German prison camps after World War II were sometimes found to have metal rods inside their fractured femurs. One such story was the subject of a 1945 article in Time magazine called “Amazing Thighbone.” A mix of curiosity and disgust followed over such apparent human experimentation, though the servicemen had actually received an advanced treatment for femur fractures ahead of its time: an intramedullary nail. The captivating thought in the anecdote, though, is that the enemy would render not just reluctant care, but outstanding care. Today is February 27, 2010. We at the 452nd Combat Support Hospital in Khost, Afghanistan, just sent a wounded insurgent, an “enemy combatant,” up range to the hospital at Bagram Airfield for neurosurgical care. He was injured in a firefight with US troops and sustained a severe head injury, chest injury, and fragmentation wounds of his arms and legs. We have been caring for this patient for the better part of two days, because ever since he was admitted, the high mountain passes out of Khost province were closed to air traffic due to bad weather. On the day he was wounded and brought to us shortly after midnight, he was critically ill. After we secured his airway, he went through CT scans, two chest tubes, a central line, warming blankets, IV drips, pain medication, sedation, and several hours of resuscitation with fluids and blood products. Around 5 AM I caught two or three hours of sleep on the couch in the operating room lounge, then got up to look in on him again. We diagnosed an arm “compartment syndrome” from where the intravenous contrast for the CT scan had infiltrated the tissues of his arm rather than flowing into the vein as intended, so I took him to the operating room to open and release the muscle compartment. We diagnosed a deep vein thrombosis in the thigh and put a state-of-the-art, retrievable clot filter into his inferior vena cava through a tiny puncture in his groin, the metal sentry silently standing guard over the patient’s pulmonary vessels. We painstakingly suctioned mucus and blood plugs from his airways when the right upper lobe of his lung, bruised and shredded from the fragmentation wounds, was not inflating properly. Unspoken in my mind, and probably in the minds of others with me, are the thoughts, Wouldn’t it be easier to let nature take its course and let this enemy combatant die of his severe injuries? He would certainly die if he was in a local hospital or insurgent aid station. Or could I just let him writhe in pain for a little longer? He wouldn’t hesitate to slit my throat if he could. Why am I busting my butt to save his? Why am I losing sleep over this guy? Maybe I could . . . ignore his declining oxygen saturation level. Maybe I could . . . not ignore him, but make him my last priority for the operating room, drag my feet in getting around to looking at his labs, put off that therapeutic bronchoscopy until tomorrow. All of these are small decision points, none of them wildly and explicitly corrupt, but all of them in aggregate may lead to a different outcome than in the conscientiously treated patient, perhaps even a fatal outcome. Then the self-justification would start: “Well, it was inevitable,” we would say. “We did what we could in the circumstances, but these things happen.” Everyone would shake their head, shrug their shoulders, disperse. It would be easy. And more convenient. But we don’t. We treat the heck out of him, losing a perfectly good night’s sleep keeping this man alive who was just trying to kill one of our fellow countrymen. Nobody was forcing us to work up each symptom, keep each other motivated, or intervene at what we thought were the right moments. Most of the nonmedical onlookers were uninterested, bored. This case had none of the “flair” of saving one of our own soldiers. The battalion commander over the team who had taken the enemy combatant down and brought him in asked one of the hospital personnel why we were “expending resources” to save an insurgent’s life. I’m not some exceptional bleeding-heart hero either; every surgeon I know would have done the same as me, I think. Why do we go to such trouble to treat our enemies? Automatic action? a trained response? fear of bad publicity, echoing Abu Ghraib? the Geneva Conventions looming over our heads? some Pollyanna notion that when we nurse him back to health, he’ll fall down sobbing and ask for forgiveness for his actions? a desire for “actionable intelligence” that he might give our interrogators once he’s off the ventilator and talking? Maybe some of these thoughts enter my mind, but the reason I went nearly sleepless that night is so that I can sleep all the other nights. It’s essentially the same reason I take extra care with each patient at home. A common phrase in my operating room is “I do it this way so I can sleep at night.” I can go to bed knowing I cut no corners, I gave each patient the best possible chance at a good outcome. There are still bad outcomes, and I agonize over those, replaying each decision in my head afterward. But I did the best I could by each one.