A Return to War

Fully telling the story of my time in Afghanistan is an impossible task; thus, in this setting, I will focus on a few pieces with varied significance. My first thought is of a lighting changing from green to red. It was Saturday, September 12, 2009, after having completed a month of US Army pre-deployment training at Fort McGrady, South Carolina, with the Navy personnel who would all travel together to Kandahar, as the US Navy had taken command of the hospital, which had enjoyed a period of Canadian leadership.

The red tactical lighting signaled that our US Air Force transport jet had entered into Afghanistan airspace. Up until that point, my thoughts had been a mix of homesickness and excitement for the mission to come, but when that cabin turned red, there was a sobering sense of fear that came over me. It was not the sort of fear that incapacitates a person, but instead, the kind of fear that is fostered by having walked through the valley of the shadow of death before. It may seem odd to the reader that I candidly admit my “fear” and don’t try to call it something more masculine. But, to do so would be dishonest. And maybe that is one of the benefits of having had three combat deployments—I’m not ashamed, nor do I feel diminished to admit my trepidation.

It is this sort of emotional journey into harm’s way that helps me to connect to my patients. I can’t say enough about how visible it can be to be speaking with a patient and to make a remark that validates their emotional experience in a way that can only come from “kind of getting it.” The emphasis is on “kind of’ because we all know that no one completely appreciates another’s experience.

This element of common experience with my patients puts combat mental health providers in a position to share more of themselves with patients than many mental health professionals would feel comfortable with. I also think it provides uniformed mental health personnel with a unique vantage point to chime in on the discussion about how much of ourselves we should reveal to patients. Frankly, even if we choose to reveal nothing in our sessions, our patients are frequently our colleagues who we lived with, exercised with, ate with, and so on while we were deployed. I imagine that professionals who work and live in small towns where they have grown up have a similar experience; without question, it makes for some very blurred lines. Conversations over dinner or discussions between sets at the gym can begin to resemble therapy sessions.

After we landed in Kandahar, we got a quick safety brief on the base, and were informed on where our temporary lodging would be, as we awaited the change of command and our assumption of clinical responsibilities. We were placed together in a gigantic tan tent full of bunk beds, each with two dusty, worn-down mattresses. It was a strange start to the deployment, with the big lead up to the mission, finally arriving, and then essentially being placed in a holding pattern. We truly had absolutely no professional obligations and nowhere to be. Our mental health team, feeling compelled to be doing something, formalized planning meetings that we conducted on a park bench in an area of the base referred to as the boardwalk.

I’m sure the Canadians would have loved to have returned home early, but international changes of command occur on a schedule. And, the scheduled date was October 1, 2009. Prior to that, there simply wasn’t space for us. Apparently we arrived weeks early out of an abundance of caution. Once again, I was familiarized with something I had learned from my time with the Marines: periods of great intensity are often punctuated by long intervals of boredom. Luckily, my past experience had taught me many wonderful ways to squander the time.

Another significant point about this period in my deployment was the exposure of our temporary tent. Having been wounded by indirect fire in the past—and knowing that Kandahar Air Field does receive indirect fire—sleeping virtually under the stars in a completely unprotected setting was unsettling to me, and left me looking very forward to the bunker-like NATO barracks to which we would move after the previous hospital staff returned home.

I believe that my first nights in Kandahar have greater relevance than just as a personal disclosure; additionally, it supports my point that every Service Member has a different deployment, even if a company of Marines had a very homogeneous set of experiences. How they process the 6, 12, or 18 months on duty is unique to them. Their prior experiences, challenges, or support from home are all different. And so are their perceptions of their social experiences with their fellow Service Members, whom they are with 24/7 month after month, as well as the thoughts they have about their own mortality. All of these factors combine to shape a distinctive experience. This point is frequently taught to those being trained to provide the best care for combat veterans: never tell someone that you know what they’re feeling because you don’t! Even if you were there, you do not know what someone’s deployment is like for him or her. You may know something about the setting and the emotions that come in the circumstances to which they were exposed, but you don’t know what they have experienced.

During September, we laid down plans, developed relationships, and spent a lot of time in the gym. We built on our training foundation as a team as we prepared for the serious responsibility to come. We also did a lot of walking from place to place. Unlike being in the USA, where it is common to drive any distance greater than a quarter of a mile, we mostly walked everywhere on the giant Kandahar Air Field, always through what was referred to as “moon dust,” a sand like none other that I had previously experienced with a consistency and clinginess that could be likened to powdered sugar. The base was like a small city, swelling to accommodate 30,000 multinational troops and support contractors. In my correspondence home, I likened the look and feel of the base to the desert world of Tatooine from the Star Wars movies. As in the movie, there were people of all different sorts walking about. The structures varied from assembled trailers covered with antennas to thick, old partially blown-out pre-Taliban era Afghan buildings to contemporary buildings that you would expect to find in any major Western city. There was even a square wooden boardwalk with Canadian and American eateries and people strolling with iced coffees while some in the middle played sand volleyball. To say it was a surreal mix, understates the strangeness of the place.

Over time, I would come to feel a sort of embarrassment of riches when I would hear of the austerity that Soldiers who were out in the fight endured. My guilt, however, was offset by my knowing that I had my past history of being deep in the dirt.

In early October, we moved into our comparatively opulent NATO barracks, and our work at the hospital began. We had hoped to be in the newly constructed German-designed hospital. It was a structure that was “rocket-proof”, yet would fit in as a regional medical center anywhere in the USA. Instead, due to construction delays, we worked out of the older structure, which was a combination of trailers and old battlefield hospital tents. It looked very modest compared to the imposing new building. But, that modest structure was a place of much healing and functioned with the speed and quality that you would find in any First World hospital. Really, it was a thing of wonder to be in such a space and see highly trained professionals working in unison through unyielding mass casualty situations.

Seeing the horrific and unrelenting nature of the wounded and dying flowing through the hospital, I quickly realized that a portion of my work would involve keeping the staff functional. The patients were most frequently from the US Army, but there were patients from all of our various service branches. There were Soldiers from various nations of our coalition, the Afghani Army, contractors, civilians and many others.

The kids were the hardest on the staff. Many struggled with an episode that occurred after a child was wounded by friendly fire. He and his father were flown by medevac from a small village. The father stroked his beard quizzically as he watched the heroic measures of modern medicine fight to save the leg of his son, who was probably 8 years old. As the clinical picture progressed, it became clear that the boy would have to have an above-the-knee amputation to save his life.

The father continued to convey a sense of confusion, ultimately leading a staff member to ask him if there was anything they could explain to him to help him better understand what was happening. With bewilderment, he remarked that it was inexplicable to him why we would make such an effort to save his son, when he would be a liability to his village after being handicapped in such a way. It was profoundly troubling that he then declared that his son was now worthless to him and that he would leave him at the gate. Immediately, it was clear that this boy would have been lucky to have died instead of being subjected to a withering death alone.

Episodes such as this one stand out, but the theme is frequently the same—First World medical staff struggling to make sense of a world where life seems cheap. Clearly, the Afghani people have had to lead lives in which they were forced to develop emotional calluses for the pain of such decisions.

During my prior, more austere deployments with the Marines, I had accepted the grunt mentality that those POGs (persons other than grunts) back on the big FOB (forward operating base) had it “easy.” I had been wrong. Whether it was the nurses in the busy hospital or in mortuary affairs, the Soldiers of the 111th Quartermaster Company who ran the mortuary affairs collection, or a Solider on guard duty making sure the tremendous length of fencing was not penetrated by a suicide bomber, all the folks on the big base had their own hardships.

My clinical work took up most of my day and ranged from what would resemble outpatient or intensive outpatient care to problem-focused brief psychotherapy, frequently, and/or medication management. Like at home, I would sometimes find myself inheriting a patient with a murky polypharmacy regiment, which I either had to change or agree to continue. The environmental precipitants were caused by exposure to war, but especially the ways that deployments exacerbate partner relational problems and conflictual occupational relationships. I felt as though my patients offered little glimpses of life within the various micro cultures within the huge base or outside the base.

I recall one Solider telling me of a conversation with an Afghani villager: “This will never work (apparently speaking of our presence in his country),” he cautioned. “We will never accept foreign rule.” The Solider related to him that our intent was not to “rule.” The man laughed at the misunderstanding and said, “Not you, Kabul.” Hearing this story, I couldn’t help but wonder about our prospects for crafting a national identity when a city about 300 miles away was regarded in such a way.

One novel aspect of my time in Afghanistan was being able to be part of a multinational team. In our mental health department, including myself, we had two Psychiatrists, a Psychologist, and a Psychiatric Nurse Practitioner from the US Navy. Additionally, we had a Licensed Clinical Social Worker from Canada and a British Psychiatric Nurse. Leading a multinational team presented chances to appreciate how things we accept as “just the way it is done” are, instead, just the American way. For example, I remember reviewing my British staff member’s notes. His notes included a robust subjective, objective, and plan section, but they seemed to be missing a diagnosis. I asked him about the missing diagnoses, and he replied, “My patients need some help, but they don’t rise to the level of having a diagnosis!” Instantaneously, I realized that our US health care system is built on diagnosis.

Even in the Navy, we follow the lead of our civilian counterparts who bill based on the diagnosis and the treatment; this is how we capture productivity. However, from those who grew out of England’s National Health Service, maybe a diagnosis is less important.

Our team was busy, but we looked forward to backup from the US Army’s 467th and 1908th Army Reserve Combat Stress Control Detachments, who would regionally reinforce our Mental Health mission. However, in the case of a national tragedy impacting our affairs in Kandahar, on November 5, 2009, Army Psychiatrist Major

Nidal Hasan went on a shooting rampage, targeting uniformed personnel at the Soldier Readiness Center Fort Hood, Texas, killing 13 people and injuring more than 30 others. This attack potentially rendered his colleagues unable to deploy.

As we watched from a distance and mourned the loss of life, we also questioned whether additional mental health assets would be sent to assist us. Ultimately, after a month delay, the decision was made that it was in the best interest of the unit not to be defeated by this radicalized individual.

As a whole, my deployment to Afghanistan was a rewarding, fascinating and educational experience. I hope that I helped a good number of people stay in the fight and recognized those who could spend no more time in theater. Two-thirds of a year can’t be condensed into a few pages, but I wouldn’t trade the deployment for anything.

Kenneth Richter Jr. This chapter covers Kenneth Richter’s time as a GMO from 2004 to 2006, residency from 2006 and 2009, and finally deployment as a psychiatrist from 2009 to 2010.

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