The Two Sides of Modern-Day American Combat: From Camp Austerity to Camp Chocolate Cake
I graduated from medical school in 2002 and have had my military medical career defined by the September 11 terrorist attacks and the global war on terror that followed. In 2003, I completed my psychiatry internship and was transferred to a Marine infantry unit to serve as the battalion surgeon. A battalion surgeon functions as the unit’s physician and is responsible for the health and readiness of over 700 Marines. In combat, he becomes the front-line physician in treating the ill and wounded.
This is an overwhelming position for any young physician new to the military. It becomes more intimidating joining a unit less than 6 months after the invasion of Iraq with a certainty of joining the fight. Psychiatry training at a military hospital, thankfully, is much broader given this possibility and includes a combat medicine course and Advanced Trauma Life Support certification.
Prior to deploying to Iraq, my only hands-on experience with chest wounds and arterial bleeds came from work on goats in the vivarium lab. Needlessly to say, I was not entirely confident my small amount of trauma training on goats and a psychiatry- focused internship would equip me adequately for what was to come.
Deployment 1: Camp Austerity
In early 2004, I left with my Marine battalion for a 7-month deployment to Iraq. We spent a few weeks preparing in the bleak tundra of Kuwait, before convoying over 30 h by vehicle through Iraq to our area of operation, Camp Austerity. My home for
J. Millegan, M.D., M.P.H., F.A.P.A. (*)
Fig. 9.1 Adaptations to the climate in Iraq
the next 7 months was no more than half a square mile in size, had no electricity, running water or walls (yet) between us and the Iraqi town.
On my second day, I was woken by the sound of 25 mortar rounds gradually increasing in volume as they came closer to where I had been sleeping. Although jarring on day two, it was amazing how common place these became as I got used to the surroundings. These became so frequent, that I became more annoyed by the mortar attacks delaying my daily chess game with the Air Officer, than worried for my safety. The vast majority of these attacks resulted in zero casualties and no visible scars to the grounds. It was easy to forget the dangers that they represented.
Once, during a mortar attack, I walked out to the command center wearing only shorts and a t-shirt, until being quickly corrected and sent back outside (during the continued mortar attack) to fetch my helmet and flak jacket. It is a jolting reminder on those few occasions when you leave cover to find a destroyed vehicle or someone else with wounds.
It was interesting how predictable the mortar attacks became. They always occurred 30 min before curfew. If we set the town curfew at 8 PM, the attacks would come at 7:30. If we moved curfew to 6 PM, the mortars would be invariably launched at 5:30. In retrospect, it was kind of funny that the attackers always respected the curfew.
Being the only Navy officer and physician on a small outpost of around 400 Marines can be a lonely place. The sense of being an “other” is strong and takes significant effort to overcome. The isolation is even stronger since, as the only physician on the base, I was seen as the person to fix others and to be a therapist to my corpsmen and the Marines when needed. Although I was in a new and scary situation with little experience to fall back on, I felt a duty to be seen as a source of stability and strength to others. That can be taxing. I have since developed great empathy for wartime mental health providers and chaplains who often serve throughout the world in solo practice settings.
The other 399 people on that small outpost all had a common identity as either Marines or grunts or corpsman. And then there was me. This isolation was fueled further by my lack of regular communication with the outside world. Camp Austerity was not a developed base with hotel-like amenities. The main vehicle for outside communication was a satellite phone. Since our base had only two of these, my regular call to my anxious wife was not a high priority to the overall mission.
Although I found opportunities to make this call, there were unique challenges for an intimate connection. The line of others waiting to connect with loved ones made any call of over 5 min a difficult task. The combination of operational security and not wanting to overly worry her made those 5 min mainly spent with pleasantries and staying relatively superficial.
On three occasions, my phone calls were abruptly stopped due to an incoming mortar attack. My wife would hear a large explosion, and then me saying, “Gotta go, bye.” This may be followed by several days of a ban of outside communication, due to a recent casualty, with my wife left to her imagination on what had become of me.
I connected with the Marines and corpsmen at every opportunity. Besides my daily chess game, I enjoyed talking with the corpsmen about medical cases, playing basketball (when it was safe), and checking regularly with the base leaders. I made many lifelong friendships out there that remain the high point of the whole experience. It is true that we fight more for each other than for any higher cause.
I came to this warzone without deep confidence in my ability to do my job as a battalion surgeon adequately. I feared being discovered as a “fraud” and, much more so, contributing to the unnecessary death of a Marine. I was very lucky that I was surrounded by experienced, combat-hardened corpsmen.
Most of my corpsmen were deploying to Iraq for the second time and had only spent 5 months in the USA prior to their last deployment. They joked about their time at home being their deployment before they returned “home” to Iraq and how they recognized a particular mound of sand and piece of sparse vegetation.
Less than 2 weeks into my deployment, I encountered my first significant casualty. The gunner on the top of a Humvee was severely wounded by shrapnel from an Improvised Explosive Device (IED) (this became a way too common situation during this deployment). He had shrapnel in his arms and head including the eye. I ran to the casualty scared as hell. My fear subsided when I saw my corpsmen spring to action and treat the life threatening injuries with minimal direction from me. Air support was miraculously fast and, within 10 min of coming into contact with the wounded Marine, a helicopter had taken him away to the closest surgical team. A few days later, we heard that the Marine survived and kept vision in one of his eyes. These corpsmen were incredible.
That was a spectacular feeling. It was the first time during the deployment that I felt that I could do this, plus may actually be able to help. Over the next few weeks, I treated many Marines wounded from IED explosions and small-arms fire and was able (with help from the corpsmen) to deliver life-saving care and hand them over to the helicopter for definitive care at a larger base. A few days later, I would hear the good news that they survived and were doing better than expected. Although the war was terrifying, there was a sense of purpose and a rush of adrenaline with each Marine successfully treated.
Then, a Marine died.
Immediately into this deployment, the Marines were engaged in combat and we were regularly under attack from mortars, direct fire, IEDs, and ambushes. It became a daily occurrence to get the call that someone was wounded and I would rush to the unarmored ambulance (this was 2004), with my corpsmen and head out to the site of the casualty.
However, in this case, when the ambulance stopped and we hopped out, there was an unnerving lack of frenzied activity. It was pitch black and all I could see were the corpsmen and the accompanying Marines looking out into the horizon, but not running toward the casualty. I was notified that a suspected mine field was between us and the wounded Marine. The wounded Marine’s vehicle had hit a landmine and was in very bad shape.
There was nothing that we could do. Eventually, a safe path was found to the vehicle but it was too late. The Marine was dead. I have never felt so helpless and useless as I did at that point. Any of the adrenaline rush associated with running to a casualty ceased at that point. This was real.
I did not get much time to reflect and grieve, as a few days later the whole town became a battle zone. That morning started with a patrol being ambushed and five of our Marines killed. That was by far the most deaths we had suffered in 1 day.
Before having time to reflect, more battles started. At one point, we were informed that over a thousand insurgents were in a mosque several blocks away preparing an all-out assault on our small base. Marines were firing their M-16s from the guard posts. One of the intel Marines suggested I grab one of the confiscated AK-47s, just in case we were overrun.
The battle lasted over 24 hours until all resistance had been defeated. As everyone returned to the base, an eerie quiet consumed us. We were only 2 months into this deployment, with 5 months to go. Was this the new normal?
Thankfully, that battle was the peak of our combat operations during the deployment. We still were routinely mortared, and there was the occasional ambush or IED attack, but we fell into a regular rhythm.
During this time, I noticed a difference in the morale and psychiatric condition between two of our companies. The small outpost where I spent the bulk of the deployment was primarily run by Bravo company. Bravo company engaged in more combat and loss than the other companies in our battalion. At the other end of the spectrum was Echo company, that was at our large, main base and was involved primarily in base protection. They saw the least amount of combat.
During my time with Bravo, not one Marine was evacuated due to a psychological or behavioral concern. Morale was high, cohesion was tight and the sense of shared duty was palpable. Echo company was a different story. They were plagued with low morale and disciplinary problems. A number of Marines from Echo were evacuated for mental health reasons.
Unit cohesion and purpose can be incredibly protective and provided an astounding layer of resilience to people facing adversity together. I don’t believe there is any therapy as powerful as being in the moment.
On our return to the USA, many of the corpsmen and Marines of Bravo company did eventually suffer from PTSD in the following months and years. But while we were there, they were all fueled by that shared duty and sacrifice.
The two worst parts of the deployment were the first death we suffered, and the final casualty before we went home. That final casualty occurred while we were turning over the base to the incoming battalion. We were less than a week from leaving Camp Austerity when one of our Marines was shot while standing watch on a guard post. The wound was “relatively” minor and he survived, but it hit me hard. Although our unit suffered scores of wounded, the fact that it could still happen so close to homecoming just seemed cosmically wrong.
Every time I have moved, I have felt some pang of nostalgia for the place I was leaving. I never felt any of this for Camp Austerity. Camp Austerity was war.