An Interlude

Less than a year after my return from Iraq, my wife and I had our first baby and I was back in the warm confines of psychiatry residency with 3 years protected from the war. In 2008, when I graduated from residency, the wars were, sadly, still ongoing and psychiatrists were in high demand in the combat zones. Less than 2 months after completing residency, I set foot in Iraq once again.

Deployment 2: Camp Chocolate Cake

I returned to Iraq as a psychiatrist and head of a combat stress team based out of Camp Chocolate Cake, a large air base with 14,000 inhabitants. I saw patients in an office embedded in an Army Combat Support Hospital (CSH). Compared to Camp Austerity, Camp Chocolate Cake was Valhalla. This base had three dining facilities run by contractors that served ice cream and cake as part of every lunch and dinner. Camp Chocolate Cake had a downtown. Let me say that again ... Camp Chocolate Cake had a DOWNTOWN.

Downtown Camp Chocolate Cake was similar to Downtown Disney, full of fun things and ways to indulge. We had our world class weight room and gym to keep us in shape. The fully stocked general store was next door with food, electronics and other comforts. Across the street, there was a barber shop, beauty salon, Burger King, coffee shop and, eventually, a Cinnabon. When the Cinnabon came in, I was half expecting a Sharper Image to open. The recreation center next door had video games and pool tables and offered such events as salsa dancing and talent shows on the weekends.

The Combat Stress Team all lived together in one of the houses on the base, with each of us having our own large room. We had electricity, air conditioning and internet in each room. Down the hall, there was a hot shower and a washing machine. Every evening, after my day of clinic, I went back to my room and talked to my wife and two daughters through Skype.

Following my conversations of anywhere from 10 min to an hour or more, I would go to the gym and work out in the weight room followed by a shower. All cleaned up, I would walk to one of the three dining facilities (which one had the home-made pizza night again?), for a nice, warm meal and maybe some ice cream for dessert. After watching a movie on my computer and checking my e-mail, I would go to bed in my twin bed and lay my head on my pillow and curl up under the comforter.

In the morning, I would wake up early and walk to the swimming pool for some morning laps while being watched by a civilian life guard. As winter approached and the water got cooler, I purchased a wet suit on that arrived in the mail a week or so later and continued my swimming. All of us on the Combat Stress Team had deployed before to varying levels of austerity and had the same thought. “I can do this time.”

Not only was life comfortable but the deployment was devoid of combat and being attacked. 2008 was the heart of the Sunni Awakening and a temporary, relative peace throughout Anbar province. We were never mortared once.

I did not realize just how calm it was until someone died on the base. The person died from cardiac arrest and was dead before arriving at the combat support hospital (CSH) emergency department (ED). After the death, the commanding officer of the CSH requested that I go to the ED to provide mental health support to the staff.

I was confused. During my last deployment, casualties were a constant and so was, regretfully, death. How could this death be so wearing to this combat medical team? I mean, they had been here more than 6 months longer than me. I asked them and they told me that this was the first death they had experienced during their entire deployment. I was shocked.

All of these creature comforts and lack of being shot at did not sit well with some of the Marines. The senior enlisted Marines on base charged with good order and discipline were clearly not pleased with Salsa Night and morning laps in the pool. I could tell this by the constant and seemingly random changes to the rules.

Later, I would refer to this as the Glow Belt Wars. At Camp Austerity, light discipline was critical to not getting shot at and one learned how to get to the urinal tubes by memory. At Camp Chocolate Cake, we wore glow belts. Glow belts were necessary so you were not hit by a passing car on the road. The rules concerning uniforms and glow belts constantly changed.

One week, the rule was to wear the glow belts everywhere, including indoors with our shiny rank devices (easier for a sniper to make out the officers). Then it would be to never wear them indoors and we had to switch to the non-shiny rank devices. I pitied the junior private who faced the full wrath of the enforcers of these rules.

Psychiatry in this environment was surreal. The first thing that stands out is the presence of a gun rack in the waiting room. Our patients would walk in with their

M-16s rifles and place them in the gun rack while we saw them. After we finished the visit, wrote any necessary prescriptions and scheduled follow-up, the patients would retrieve their M-16 and walk out.

Therapeutic rapport is important in any environment but it seemed exceptionally more so in Iraq where you would see your patients wondering the base carrying an assault rifle. I was always very aware of the possibility of a disgruntled Marine opening fire on the base. A few months after I returned home, an Army soldier opened fire on the members of a mental health clinic at another base in Iraq, making this fear, tragically, prophetic.

Besides the creature comforts and the lack of being constantly shot at, what made this deployment much more bearable than my first one was that I had regular work to do. At Camp Austerity, I was either bored out of my mind or completely terrified. At Camp Chocolate Cake, I saw a full panel of patients daily. Patient problems included continued treatment of preexisting conditions, substance-induced psychosis, mood and anxiety problems as well as difficulty coping with deployment, work or family separation.

Family-related problems were interesting. At Camp Chocolate Cake, we all had ample access to means of communicating with home. This was a Godsend for most (me included). Others on the base would clearly have been better off without unlimited access to home. The combination of being intimately aware of all of the home front problems, but being thousands of miles away, led to MANY visits to my office.

The people on longer deployments were given a 2-week period to visit home during their deployment. I saw a ton of people upon their return from these leave periods who were dealing with the sensory overload of returning home, being flooded with home problems, and then being thrust back into the deployed environment. I felt fortunate that, due to the 7-month length of my deployment, I did not have to manage this jarring 2-week return home.

Military psychiatrists become very aware very quickly which units have a morale or leadership problem. We become aware because a disproportionate number of our patients come from a few units. One of these units was an Army company whose job was base maintenance. The problem was that base maintenance was done primarily by contractors making the company’s jobs somewhat redundant. The morale problem peaked with a cluster of their soldiers coming to my clinic within a week of each other reporting homicidal thoughts toward their leadership.

Each soldier came in with a more over-the-top plan for how they would kill their leadership and each time I recommended they be sent home. By the seventh soldier, the company commander pushed back at my recommendation for evacuation fearing (appropriately) that eventually all of his soldiers would be sent home. I convinced him that his resistance was not worth the risk and the soldier was sent home. After he left, the homicidal threat cluster stopped and his unit’s morale improved.

At the end of my deployment, with my relief on board, I was excited to go home and rejoin my wife and two young daughters. But, as opposed to my unsentimental feeling about Camp Austerity, I did feel that usual wave of nostalgia before leaving Camp Chocolate Cake.

My daily video chats with my family allowed me to remain connected to them and especially to maintain a relationship with my 2-year-old. I don’t know how I would have connected with her through only an audio connection. I had regular work that I felt a sense of competence at and was proud of the care I provided to my patients. I was in the best physical shape of my life, from daily morning swims and evening weight training. I was surrounded by behavioral health techs, other mental health professionals and Navy medical/dental officers to connect with and share the experience with.

We all laughed at some of the absurdity at life on a large, quiet base in a combat zone and never felt threatened or experienced the tragedy of combat wounded or deaths. This did not feel like war but more like some bizarre summer camp.

Combat experiences of a psychiatrist are a very broad subject as illustrated by my two experiences above. Although Camp Austerity has clearer evidence of adversity and stress associated with it, it is important that we do not quickly discount experiences from places like Camp Chocolate Cake. Although I found connection and purpose at that base, there are many people who will struggle much more at a place like Camp Chocolate Cake, due to lack of a clear link to the greater war effort, more isolation given the large numbers of people on the base and a harder time finding how their efforts are important. Every deployment to a combat zone has its unique hardships and opportunities. Although for me ... I’ll take Camp Chocolate Cake every time.

CDR Jeffrey Millegan is a Navy psychiatrist who has deployed twice to Iraq, once as a Marine Corps infantry battalion surgeon and then as a psychiatrist. This chapter contrasts the experiences of two very different deployments to a combat zone.

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