Major Jason Stamm
Balad Air Base. approximately 40 miles north of Baghdad, is home to The Air Force Theater Hospital. The hospital is a joint effort of the U.S Army and Air Force.
How I Spend My Time
Apart from the caring for the occasional internal medicine patient, I spend the majority of my time working outside of the usual realm of the internist. In the noisy combat hospital, conventional internal medicine patient evaluations are impossible. The history is often limited by the patient’s physical condition and, for many of the Iraqi soldiers, a language barrier. Physical exams are done more with sight and touch than with a stethoscope. The past medical and surgical history is uncertain. The knowledge and skills required to care for these trauma patients are also a departure from routine internal medicine practice.
Fortunately, I discovered that, although little used since residency, my ability to manage ventilators and to perform invasive procedures was quick to return and was immediately put into practice. I have learned aspects of critical care as practiced in the theater hospital ICU that I was unfamiliar with initially—such as the intricacies of post-operative and trauma care—on the job. I have become familiar with dressings, drains, and the concepts of resuscitation and of “secondary survey.” I have acquired a working knowledge of the various types of surgical procedures performed, and the subsequent care required thereof, in trauma patients. I have become familiar with treating elevated intracranial pressure in patients who have had craniotomies for penetrating brain injuries, with monitoring airway pressures and oxygenation in patients with blast-related pulmonary contusions, with following bladder pressures and serial exams in patients with abdominal trauma, and with managing chest tubes in patients with penetrating thoracic injuries.
I have even overcome a reluctance shared by many in internal medicine and have learned to look under surgical bandages—a feat that may undermine the truth that gives rise to the joke about hiding something from internists. Perhaps the most important concept I have learned in caring for combat trauma patients in the ICU is vigilance.
The primary survey, completed by the emergency medicine and trauma surgeons, usually discovers and addresses the large or obvious wounds that bring patients to our facility. When the patients arrive in the ICU after having their initial resuscitation and “damage control” operative intervention, it falls to the intensive care physician to both continue resuscitation and to look for as yet undiagnosed or delayed injury presentations. This constitutes the secondary survey and is an ongoing process. Patients often arrive in the ICU still recovering from their injuries; they require close attention to physiologic parameters such as temperature, heart rate, arterial pressure, and urine output. Their laboratory measurements, including oxygenation and ventilation, acid-base status (e.g., a reliance on the base excess, a tool more familiar to those in surgery than in medicine), hemoglobin concentration, and indices of coagulation, require constant attention.
In addition, patients often come to the ICU with vascular lines that were placed in the field under less than sterile conditions and require replacement. While major wounds have usually been addressed, minor wounds (such as missed fragments of shrapnel and subtle vascular injuries) or delayed presentations (including blast injuries and compartment syndromes) must be identified in the ICU and mandate constant awareness.
Specific Challenges
There are challenges, both personally and professionally, to working in a combat zone. Like everyone here, I am away from family and home for an extended time. Although fairly secure, one’s personal safety from ongoing mortar attacks is also an emotional burden. The hours are long and the recreational opportunities are limited on base. Traveling off base is strictly limited for obvious security reasons and most hospital personnel spend their entire tour in Iraq within the confines of the base perimeter.