Return and Reunion

Those from Division who returned with me did not know what was going to greet us. We boarded a bus and turned in our weapons. We then got back on the bus, unsure where we were going. We were not sure if there was a return ceremony, but we were delighted to find our families and the band.

My wife was in her final trimester when I returned. My 6-year old daughter, Kristabel, was by her side holding a welcome home sign. I was able to return home to attend the birth of my son. A few days off and then back to finish the redeployment process. Paternity leave gave some time, but the mission had to again come first.

At the time, I felt that I had helped the Iraqi people. I felt good when people would thank me for my service. At the same time, it was difficult to turn off the television news. It was tough to adapt to being home. Everything was different after returning from combat. I found myself falling asleep on the couch, watching the news, wondering what was happening to those left behind. This never fully resolved.

I was shocked and grief stricken when I heard that my friend, Margaret Hassan, a nongovernmental organization (NGO) aid worker, who had worked with me at the CMOC, was killed after she had been abducted. She had taken aside a brash young officer and reminded him that the Iraqis had many good people trying to rebuild their country. She was truly a wonderful person, who loved her country. There were many good people left behind in Iraq.

Clinical Pearls

Medications for front line troops need to be capsules, not pills, and kept in Ziplocs. With all the other gear required, crush proof containers only add unwanted bulk. When Marines go prone, whatever is in the pocket that is crushable is crushed. Medications and medical records don’t do well in harsh environments.

Like all medical encounters, it’s not over until the paperwork is done. Unfortunately, paper is not as easily accessible, maintained or protected in deployment. In the desert, everything gets wet and dirty if it isn’t in a Ziploc bag, including medical records and Post Deployment Health Assessments (PDHAs).

It is impossible to understand how austere it really is during an invasion with the Marine infantry. Discipline is essential to minimize DNBI (Disease and Non Battle Injuries). Compliance with medications and sanitation (e.g., slit latrines) is more than just education. Knowing and doing are two different things. Although dental made sure teeth were in good repair, making sure to brush teeth was a challenge.

There was no routine in combat to facilitate habits. Keeping sleeves down with temperatures over 120 °F is not an easy order to follow, especially with how hard it was to drink warm water. Sleep was poor; fatigue was an unwanted alternative. Stimulants could extend work hours, but too much produced adverse side effects.

Constipation can be a significant problem, particularly for senior male Marines. When women were assigned at headquarters and regiment, male Marines were concerned about the women seeing them use the bathroom. Many utilized NVGs (night vision goggles) to go at night when no one else could see them. The women had no problems going to the head together, but the men were disturbed by the possibility of sharing. Once when the privacy netting was too high, some men expressed concern that the women could be seen using the head. One outspoken female Marine said, “If someone is sick enough to get excited watching me use the head, that is their problem, not mine.”

Humans were never designed for riding in poorly cushioned Humvees on rough terrain or for wearing body armor and equipment weighing more their own body weight. Back problems and hernias were not a surprising result after the deployment.

Deployments are depleting. Exceeding tolerances of the human mind and/or body results in breakage and failure that may not manifest until much later. Endurance is lost without conditioning. Asthma can result from environmental exposure. Orthopedic injuries increase if Vitamin D is low. Despite being in the desert, sun exposure is limited with sleeves down and use of sunscreen.

Managing combat stress is the role of leadership, not just clinicians. I saw this first hand when General Mattis required all units to attend an out brief with him before leaving theater. In it, he told every Marine and Sailor, “You have seen a lot of difficult things. You have done some amazing things. Remember: you are responsible for all those heroic actions. I am the one who ordered you to do some of those difficult things.” Ideally, all commanders will be as aware and dedicated to managing combat stress.

Operational psychiatry cannot be delivered from an office based consultation model. The Division Psychiatrist must be out with the war fighters to gain trust and recognition. When a psychiatrist has not established a relationship with combat troops, they are perceived as outsiders.

Culture shock on return is inevitable and difficult to distinguish from trauma. There is thin veneer of civilization. I believe one of the most troublesome existential realities is how things are not fair and how they can fall apart so quickly. In learning about NBC threats, it was pointed out that the initial clinical presentation often gave little clue of a specific agent or infection. Readjustment or redeployment was a lesson on how difficult determining pathology can be.

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