February 2004 Bulletin

Orthopaedists serve in Iraq

Endure hardships, improve medical care in embattled country

By Carolyn Rogers

Orthopaedic surgeons have long played a crucial role at times of war, and the ongoing conflict in Iraq is no exception. Although an accurate tally is not available, it's safe to say that dozens of orthopaedic surgeons have been deployed to various parts of Central Asia in support of Operation Iraqi Freedom and Operation Enduring Freedom, with many others serving stateside in the U.S. military hospitals. This article focuses on the experiences of two of those orthopaedic surgeons—Maj. Timothy A. Gibbons, MD, a reservist from Mason City, Iowa, who returned to the United States in December 2003 after 10 months of active duty in Iraq; and Lt. Col. Greer E. Noonburg, MD, a military surgeon from Fort Stewart, Ga., who is scheduled to leave Iraq in late March after a 12-month tour of duty.

Revitalizing Iraq's medical community

Timothy A. Gibbons, MD
When Timothy A Gibbons, MD, decided to join the National Guard as an orthopaedic resident in the early 1990s, he never imagined he would one day find himself at the center of world events, working alongside ambassadors and generals at Saddam Hussein's presidential palace compound in Baghdad, watching history unfold before his eyes.

Called to duty in Iraq
Dr. Gibbons, an orthopaedic surgeon in Mason City, Iowa, was called to active duty in support of Operation Iraqi freedom in late February 2003. Within 48 hours, he and 70 other members of the 109th Area Support Medical Battalion were headed for an active duty mobilization station in Wisconsin. His unit landed in Kuwait on April 7, two days before Baghdad fell.

Dr. Gibbons (right) shares a throne with former medical school classmate Col. Tom Colburn at a palace in Baghdad.

After spending six weeks in a troop assembly area in Kuwait, Dr. Gibbons was transferred to the Mosul area of Northern Iraq, where he was attached to the 21st Combat Support Hospital (CSH). About a month later, the commander of the medical brigade in Iraq—Col. Donald A. Gagliano, MD—called him to Coalition Joint Task Force 7 headquarters in Baghdad.

"He asked if I wanted to be involved in a special project to reorganize the Iraq medical community into professional, non-governmental medical societies," Dr. Gibbons says. "So I said, 'sure!'"

Dr. Gibbons stands outside his hut at a troop assembly area in Kuwait.
This new assignment required him to relocate to the "Green Zone," a heavily guarded, four-square-mile area in central Baghdad encircled by 15-foot concrete walls and rings of barbed wire. Saddam Hussein's two-square mile Republican Palace compound lies at the center of the Green Zone, and now serves as the headquarters of the Coalition Provisional Authority (CPA) that temporarily governs Iraq.

"A micro-model for Iraq"

With an estimated 20,000 physicians in Iraq, 2,000 Iraqi doctors in the States, and at least 2,000 Iraqi-born physicians living in the U.K., Dr. Gibbons says, "Iraqi medical societies have a lot of potential members."
Although he didn't meet all of them, "I met more Iraqi physicians and I've been to more Iraqi hospitals than any other coalition soldier," he explains.
Under Hussein's rule, Iraq's medical associations were "essentially political tools of the Baath party," he says. "They were primarily a mechanism for creating titles for the egotistical and the politically 'in' group."

Through this U.S. Army-inspired project, the Iraqi physician community will have an opportunity to elect new leadership and create a new Iraqi medical society that is democratic, transparent and fair, he says.

"The project is really a micro-model of what [U.S.] Ambassador Paul Bremer is trying to do with the entire country," he says. "There are so many complicating factors—religious, cultural, ethnic, women, specialty vs. nonspecialty, money, socialized medicine vs. private enterprise…It's very complex."

Cultural hurdles
Iraqi physicians are "universally excited" about the project, Dr. Gibbons says. Even so, bringing together physicians from varying ethnic, religious and geographic backgrounds to form a national, democratic medical society in Iraq is not an easy process.

Some Iraqi doctors, for instance, "find the very concept of democracy, appropriate leadership and term limits very hard to swallow," he says.
Another cultural "hurdle" is the manner in which Iraqi physicians earn status among their peers. "In America, to distinguish yourself as a physician at the highest levels, the question is, 'How many peoples lives have I touched?' or 'How much information did I disseminate?'" Dr. Gibbons says.
In Iraq, it's the opposite. "Physicians in Iraq earn status based on what they know and what they can do," he explains. "If they disseminate that information, it weakens their power. So adapting to an open system will require a major transition in thinking."

The hostility many physicians feel toward former Baath party members also presents a challenge.

"All Baathists weren't necessarily bad people," Dr. Gibbons explains. "Just because someone was a member of the Baath party doesn't mean they were out there signing death certificates or torturing victims. Then again, some were. So determining who was a Baathist 'player' and who was a Baathist 'non-player' became another aspect of our mission."

Iraqi Medical Specialty Forum
That mission culminates Feb 14-17, 2004, in Baghdad at the "Iraqi Medical Specialty Forum." Organizers expect between 1,000 and 1,500 Iraqi physicians to participate on each day of the forum. The doctors will travel to Baghdad from as far north as Kurdistan and as far south as Basra.

"Iraqi physicians are eager to rejoin the international medical community, and they're starving for updated education and training," says Dr. Gibbons, who will return to Baghdad for the forum.

A total of 30 U.S. and U.K. specialists, including nine Iraqi-American physicians and three Iraqi-U.K. physicians, will travel to Baghdad to take part in the forum. These physicians — representing every specialty in which Iraqi physicians are trained — will serve strictly as facilitators and will not define any conditions or terms for the reorganization of Iraq's medical societies.
The project is endorsed by the CPA, and by Iraq's new Ministers of Health and of Higher Education, both of whom will speak at the forum.

The academic component of the program will be largely devoted to updating Iraqi physicians on many of the medical and technical advances they've missed out on over the last 20 years. Multi-disciplinary activities will include restructuring the emergency medicine system, remodeling the primary care infrastructure and integrating a new nursing education system.

The Iraqi medical specialty societies are expected to officially proclaim their independence at the forum and also to re-charter under the projected new constitution. Organizers hope that once the Iraqi physicians are together, the leaders within each society will come together to form regional medical societies as well as a national society.

"There's a lot of talent in that country," Dr. Gibbons says. "Many of those doctors could be in America, operating at the highest level. They're just in desperate need of good leadership."

"Organized crime at its finest"
It's difficult to overestimate the amount of work that will be required to get Iraqi health care back on track. Decades of rule by the Baath party, and more than 13 years of economic sanctions, have left the country's health care system in shambles.

"To a certain extent, Iraqi people fear their hospitals," Dr. Gibbons says. "They'll only go to them in most desperate of circumstances. Most gas stations in America have cleaner bathrooms than the hospital bathrooms in Iraq."

"But that's socialized medicine in a corrupt government," he adds.
Ruling Baathists squandered the country's resources, he says. Kickbacks and illegal commissions on oil contracts under the U.N. oil-for-food program netted the regime more than $100 million in funds earmarked for humanitarian aid for the Iraqi people. And that's in addition to the $1.5 billion to $3 billion Hussein pocketed in oil smuggling revenues each year.

"It was organized crime at its finest," Dr. Gibbons says.

Access to education
Prior to the 1980s, many Iraqi physicians had the freedom to pursue residencies and other educational opportunities in the U.S., the U.K. and Europe, Dr. Gibbons says.

Unfortunately, those opportunities dwindled when the Baath party came to power and "slowly strangled Iraq's entire economy," he says. "Then—after the Iran-Iraq war in the 1980s—Iraq was ostracized from the rest of the world. Following the Persian Gulf War, they were isolated."

Economic sanctions instituted in 1990 meant that Iraq could not import any medical books or journals. Internet access has been available to Iraqi physicians only for the last two years, and that was through a government server. "So they weren't able to roam freely online," he says. "Contact with any American at any level would have put them under suspicion for treason. Even a casual correspondence could result in jail or death."

The result is a country that is at least 20 years behind the United States in terms of medicine and medical technology, Dr. Gibbons says. "In terms of hospital administration, they're 50 years behind, and in terms of nursing, they're 100 years behind. There's a lot of work to do."

Car bombs cause "hellacious damage"
As involving as the project was, Dr. Gibbons' activities in Iraq were not limited to the re-invigoration of Iraq's medical societies. While working in the Green Zone, he was recruited to be part of the Rapid Advance Medical Team (RAM-T) that responded to all of the bombings in and around Baghdad.

Also responded to the bombings at the U.N. building, the Jordanian Embassy, the Baghdad Hotel and the rocket launch on the Palestine Hotel, to name a few.

His RAM-T also was called to the scene when Aquila al-Hashimi, one of three women on the U.S.-appointed Iraqi Governing Council, was gravely injured in a September ambush.

Car bombs are capable of "some hellacious damage," he says. "Fortunately, the protection system the military has in place is working."

Meanwhile, back at home
Dr. Gibbons received a hero's welcome when he returned home to Mason City on Dec. 13, 2003. Although he calls his 10 months in Iraq a "wonderful experience," he says the time away from his practice would have been "financially devastating" if his partners at the Mason City Clinic hadn't been so supportive.

"My partners are really wonderful people," he says. "They've done so much for me, I really can't say enough about them."

The long absence wasn't easy on his family, either. "It was probably rougher on my wife than it was on me, " he admits. "But she handled it well. And the Internet definitely helped."

Watching history unfold
Summing up his experience, Dr. Gibbons says, "It was fun and it sucked at the same."

While in Iraq, his 'home' varied from a tent, to a looted, bombed-out building, to the basement, hallway and roof of a presidential palace. His last residence was a trailer by the Tigris River in the Presidential Palace compound.

Although the living conditions and the "god-awful heat" were trying at times, Dr. Gibbons says he enjoyed his work in the Green Zone. He treasured the opportunity to observe some of the world's top military and civilian leadership at work and "watch the decision-making process up close," he says. "It's amazing to be right there when history is happening."

He describes Lt. Gen. Ricardo S. Sanchez, who commands the 38-nation alliance of occupation forces in Iraq; Ambassador Paul Bremer, administrator of the CPA; and Kevin Kennedy, the top U.N. official in Baghdad, as "some of the greatest guys you'd ever want to meet."

Dr. Gibbons also has high praise for American soldiers.

"Americans can be extremely proud of the way their army is conducting itself," he says. "It's a tough, dangerous situation for these guys, but I didn't hear people [complaining] about food or living conditions. And unlike other wars, there have been no drunken activities or thefts—other than some minor, petty things. The American people can be proud of their soldiers."

In spite of the many challenges and obstacles that lie ahead for the country, Dr. Gibbons seems hopeful about the future of Iraq.

"The Iraqis are wonderful people," he says. "Some of them are the most delightful, courageous people I've ever met in my life. They have huge potential."

In the heart of the Sunni Triangle

Lt. Col. Greer E. Noonburg, MD
It's been 11 long months since Lt. Col. Greer E. Noonburg, MD, and the rest of the 240th Forward Surgical Team (FST) were deployed to Iraq in support of Operation Iraqi Freedom. Unlike many other Fort Stewart, Ga.-based units, however, homecoming celebrations for the 240th FST remain "on ice" until early spring.

Dr. Noonburg's team is currently situated at a U.S. base camp near Baqubah, Iraq, which lies at the heart of the country's most volatile region—the Sunni Triangle. Their mission—to support the 4th Infantry Division (ID) soldiers who patrol this dangerous area north of Baghdad—remains as vital today as ever.

Lt. Col. Greer E. Noonburg, MD, (front row, 2nd from right) and
several members of the 240th Forward Surgical Team pose with
actor Bruce Willis (top row, 4th from left) who visited the troops
in Kirkush—a remote, desolate area 60 miles northeast of Baghdad.

Convoy cheered on route to Baghdad
Dr. Noonburg, an orthopaedic surgeon and former member of the Green Berets, landed in Kuwait in March 2003. He crossed the border into Iraq with the 4th Infantry Division in early April.

From there, the soldiers embarked on a two-day convoy to Baghdad. "As we passed through the many towns and cities along the way, people came out of their homes to cheer and wave," he says. "They were clearly happy to be rid of Saddam—all the larger-than-life public portraits of him had been defaced or were torn down completely."

As the troops neared Baghdad, he could see destroyed Iraqi tanks and armored vehicles scattered
"The effects of precision bombing were evident," he says. "Some government buildings were destroyed with 'direct hits' while the surrounding structures were left untouched."
Forward surgical teams

Members of the 240th FST set up their surgical tents at Al Taji Airfield, a few miles north of Baghdad. Later, they moved with the 4th ID on to Samarra and then to Saddam Hussein's hometown of Tikrit.

The 240th is one of six FSTs currently deployed in Iraq. The 20-person teams— which are composed of two to four surgeons and more than a dozen nurses and medics—are able to set up an emergency treatment area, operating room and post operative recovery area in tents within two to three hours of arrival.

At the Baghdad Airport, Dr. Noonburg stands before a larger-than-life defaced portrait of former Iraqi leader Saddam Hussein.

The FST concept was created when Gulf War battlefield commanders recognized that lives could be saved if surgeons moved with the infantry into combat. FSTs remain a few miles behind the front lines, where they can quickly treat severe wounds. After surgery, patients are transported to larger combat support hospitals (CSH) for further treatment.

Following their arrival in Tikrit, combat operations were ongoing, with frequent, sporadic gunfire in the vicinity and occasional mortars fired into the camp. During that time, Dr. Noonburg operated on U.S. soldiers, Iraqi civilians, and enemy prisoners of war, though fewer than he'd expected. Most of the patients' injuries were stable enough for transport to the nearby CSH.

Saddam's "opulent lifestyle"
While in Tikrit, Dr. Noonburg visited the 4th ID headquarters, which was located in one of Hussein's palaces in Tikrit.

"Saddam's opulent lifestyle contrasted sharply with the impoverished people living outside the gates of his palaces," he says. "There are more than 40 incredibly ornate buildings inside the compound, which occupies more than 10 square miles along the Tigris River. Each structure has a different sandstone exterior with elaborate Arabic designs. The floors are all marble and the furnishings were very detailed, although somewhat gaudy."

His tent in Tikrit was "not nearly as impressive," he jokes.

Their tent was located next to the runway for easy access to the Med-Evac helicopters, so they had to endure daily sandstorms that left everything covered with a thick layer of brown powdery dust.

"Our living conditions were austere," he says. While in Tikrit, food and water were rationed much of the time, and clothes were washed in a bucket.

Then there was the unrelenting heat.

"Summer temperatures typically reached 120º to 130º F," Dr. Noonburg says. "We finally got air conditioning late in the summer and it made a huge difference."

"Donkey killer"
In August, his team was sent to Kirkush, an extremely desolate camp near the Iranian border, 60 miles northeast of Baghdad. Although convoys were occasionally ambushed in Kirkush, the area was more stable than Tikrit.

"Land to the north is controlled by the Kurds, who are very happy to have the Americans here," he explains.

Despite its remote location, the Kirkush camp was equipped with a satellite hookup with Internet access. "Yesterday it was 126º in the shade, 140º in the sun," he wrote in one e-mail. "I think it's the equivalent of 110º in Chicago in the cheap seats at Wrigley Field."

In spite of the trying circumstances, Dr. Noonburg managed to retain his sense of humor.
"The name 'Kirkush' is Kurdish for 'donkey killer,'" he writes in a later message. "According to local lore, when the spice trade caravans came through here during the Middle Ages, they were able to follow the route through the featureless desert by following the trail of donkey carcasses… Doesn't that brighten your day?"

Later, Dr. Noonburg mentions that the actor Bruce Willis visited Kirkush via helicopter the day before. The visit impressed him, he wrote, because "no one ever comes to this remote spot willingly."

U.N. building bombing
During slow periods, Dr. Noonburg traveled to the 21st CSH in Balad to work with one of his residency mates, Maj. Clark L. Searle, MD. One of those visits coincided with the bombing of the U.N. building in nearby Baghdad; the 21st admitted more than 20 casualties.
"There were some terrible injuries," he says. "Clark and I operated all that night and well into the next day on several of the patients with serious blast injuries."

Dr. Noonburg was very impressed with the staff at the CSH, which by that time was quite adept at handling mass casualty situations.

Around this time, Dr. Noonburg and Maj. Jeff Casto, a general surgeon, began traveling two days a week to a Kurdish town to the north called Khanaqin.

"With the assistance of some Army civil affairs officers, we worked with the Iraqi physicians in Khanaqin to get the small hospital re-equipped after years of Saddam-orchestrated discrimination against the Kurds," he says.

Drs. Noonburg and Casto also saw patients at a weekly clinic in Khanaqin. "There were many unusual cases, including untreated developmental dysplasia of the hip in young adults, and several chronic cases of osteomyelitis and fracture nonunions sustained during the Iran-Iraq War in the early 1980s," he says.

Patient privacy not a concern
One surprising feature of medical care in Khanaqin involved a "very different concept of patient privacy than most Americans would accept," Dr. Gibbons says.

"As soon as I arrived at the clinic, my exam room would quickly fill up with patients trying to get my attention by talking or handing me their X-rays while I was in the middle of examining someone else," he says. "Despite a line out the door, they would just push into the room until it was completely full."
In the inflatable operating room/tent, Dr. Noonburg
takes intraoperative x-rays while debriding shrapnel wounds from the arm of a soldier.

In spite of the occasional chaos, they found their visits to the Khanaqin to be very rewarding. "We developed some very close friendships with the Khanaqin hospital staff," he says.

While they had some success improving the facility, their visits came to a halt when the 240th FST was moved to Baqubah, a city approximately 30 miles northeast of Baghdad.

Frequent ambushes, gunfire, mortar attacks
"Unlike Khanaqin, there is a lot of enemy activity in Baqubah and the area is still quite dangerous," Dr. Noonburg says. "Several convoys that I've been on were shot at [by Fedayeen] while moving though this area."

The American base camp at Baqubah sits astride the infamous "RPG Alley," the site of numerous rocket-propelled-grenade attacks on U.S. convoys. "Ambushes involving improvised explosive devices are common in this area," he says.

Consequently, their compound is very heavily fortified and security is tight. After their arrival in October, the camp was averaging three to four mortar attacks a week. During one of the attacks, "a mortar round landed a few feet from our FST treatment area, but thankfully it didn't go off," he says.

Initially, the team was treating soldiers injured in the ambushes on an almost-daily basis. "Most of the wounded soldiers are stable for transport to the CSH, which is only seven minutes away by chopper," he reports. "But some need immediate stabilization such as intubation and chest tubes."

FST management of casualties requires a different philosophy about trauma treatment, Dr. Noonburg says. "Instead of thinking in terms of definitive injury and fracture management, I've had to reorient my practice to immediate stabilization, triage and rapid transport to a better-equipped medical facility."

The mortar attacks on the camp had lessened by early January, he reports. "Aggressive raids by the 4th ID in the past month or two have rounded up a lot of troublemakers, so the mortaring of our camp has dropped to one to two times per week."

Hussein's capture "a big morale boost"

In April 2003, Dr. Noonburg stands before a destroyed surface-to-air missile site south of Baghdad.
The Dec. 13, 2003, capture of Saddam Hussein also played a role in reducing the number of attacks. Six hundred 4th ID soldiers participated in Operation Red Dawn —the mission that led to Hussein's capture at a sheep farm outside Tikrit.

Capturing Hussein was a "big morale boost" not only for the soldiers, Dr. Noonburg reports, but also for the Iraqis who are trying to rebuild their country.

"From my perspective, things seem to be improving here for the Iraqi people," he writes in a January 13, 2004, e-mail. "The U.S. reconstruction effort has led to improvements in the roads, electricity and water. New schools and buildings have been constructed. Even when I go through areas that have been the site of attacks on American soldiers, many people still come out and wave as we go by. The markets are bustling and towns seem to be conducting business as normal."

When the 240th FST begins its journey home to the United States in late March, Dr. Noonburg won't be leaving Iraq empty-handed. He's documented the experience with dozens of photographs that capture not only the brutality of war, but also the beauty of Iraq and the resilience of its people.
That seeming contradiction mirrors Dr. Noonburg's experiences in Iraq as a whole. He describes his yearlong deployment on Operation Iraqi Freedom as "both rewarding and trying at the same time."

Although the circumstances have been challenging and the living conditions harsh, he adds, "This experience has led me to appreciate the freedoms we often take for granted at home."

Symposium on military medical service in Iraq

A significant number of military orthopaedic surgeons have been deployed to various parts of Central Asia in support of Operation Iraqi Freedom and Operation Enduring Freedom.

In a special symposium on Thursday, March 11 at the 2004 AAOS Annual Meeting in San Francisco, several military surgeons will discuss their experiences and lessons learned, as they relate to the demographics of both battle and non-battle injury patterns; treatment of wounded soldiers from initial management in the theater to definitive management in the United States; treatment of injured civilians and enemy prisoners of war; current amputee care; air evacuation policy; and the doctrinal evolution of our current forward surgical teams and combat support hospitals.

The symposium will take place from 1 to 3 p.m. Thursday in the Moscone Convention Center, Room 304-08.

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