A doctor on deployment treats more than the individual.
Looking out across the vast desert, I see a massive wall of sand and dust rapidly approaching our position. This colossal and ominous force of nature is one of the bigger sand storms we have experienced while deployed to the Middle East.
It is exhilarating to be halfway across the world in a land invaded by countless nations over time. The climate is oppressively hot and the wildlife almost alien. Although seemingly devoid of life in most places, this region is rich in cultural history. Even so, I sometimes wonder how humans have managed to live here for so many years.
My unit is deployed here for six months. We are on an Air Base that has supported US and coalition military forces for nearly two decades. I am one of several medical officers on base, but I am attached to the only Marine Corps infantry battalion deployed to this region.
Deploying for the first time with my unit to this part of the world has been a culture shock. It is certainly different than practicing medicine in a hospital setting. At the same time, I have learned so much in my few months on the ground. It has been more than just keeping the sand out of my eyes; more than just seeing patients in clinic. Practicing medicine in an operational and deployed setting presents unique challenges and has forced me to learn lessons I could learn nowhere else.
Having to work with limited resources forces a provider to decide whether they can give adequate care on site or must transfer a patient to another facility. I have run into this issue multiple times. I recall one patient whom I believed had a kidney stone. He was in quite a lot of pain, and his blood work showed signs of kidney injury. Normally I would send him to the emergency department for a CT scan. Here, however, transferring a patient to a hospital with imaging capabilities would be a four- to five-hour process requiring much coordination: putting together a mission summary memorandum, requesting command approval, obtaining vehicles for transport, and making sure the weather will permit ground movement. Until now, I had never been involved with the logistical side of medicine. But without a logistical framework in place, adequate medical treatment cannot be provided here.
Another challenge has been the sheer volume of men and women who fall under my care. We deployed with almost 1,000 Marines and sailors who are now spread out across multiple countries in the region. Preparation and pre-screening alone are difficult: pre-deployment HIV testing, mandatory neurocognitive examinations for all personnel, screening for disqualifying medical conditions, and more. Travel to different countries also requires certain vaccinations, such as polio. Prophylactic malaria medications are required for others. This process is necessary to prepare our troops for battle, but it can certainly be cumbersome and time consuming.
One of the more interesting differences in practicing medicine in the military is the way patient privacy is treated, especially while deployed to a combat zone. Until now I had considered this a fundamental, relatively unbreakable principle of patient care. What is discussed in the exam room stays between patient and provider. In this setting, however, there is some gray area when it comes to privacy.
More than once a Marine has approached me wanting to discreetly discuss a medical issue. Usually their first question is whether any information will be shared with command leadership. The response to this question is not a simple “yes” or “no.” Privacy must be respected, but the command needs to be notified if a patient presents a risk to themselves, others, or the mission. Often there is a lot of discretion left to the provider on how to handle these situations.
What do you do when someone discloses a preexisting medical condition? Take, for example, a Marine who admits he was diagnosed with Wolff-Parkinson-White syndrome several years before. He is fully functional and exercises every day but sometimes experiences palpitations. By regulation, this is a disqualifying condition and he should not be deployed. From a medical perspective, he warrants evaluation by an electrophysiologist and possibly an ablation procedure, which could be curative. At the same time, the chances of him developing a fatal arrhythmia while on deployment are small. In all likelihood he could finish out this deployment without any problems. Additionally, this particular Marine’s absence would create a significant leadership gap if he were to be sent home, not to mention the tax dollars that would then be spent to fly out a Marine to replace him. In the end, there is no way to reliably predict what will occur, but a judgment call must be made.
Perhaps it is wrong to consider what effect medical decisions will have on a unit’s operational readiness. Some would argue that medical decisions should be made solely with the patient in mind. While there is some merit to this, I believe military medical providers must strike a balance between what is good for the unit and what is good for the patient. I cannot make my decisions in a vacuum: I have to consider how my decisions and interventions will affect my unit’s warfighting ability. Sometimes this means going against a patient’s wishes. Sometimes it involves bending regulations in extenuating circumstances. Just as often, though, I must make medical decisions that my command leadership does not support. Going against a superior officer is difficult but can be necessary for a patient’s sake. In many ways I act as a liaison between the medical and operational communities, which means I need to be well-versed on both sides.
Working with a Marine Corps infantry battalion has been an eye-opening experience. Some days are difficult, physically and emotionally. Learning to navigate between the medical and military communities has been an exercise in adaptability and mental fortitude. The greatest reward is becoming part of a brotherhood that has stood the test of time for more than 200 years. I am not a Marine. I do not hold a rifle in battle. In reality, I am an outsider within my unit. But I feel a sense of belonging here that I have felt nowhere else. My career as a military medical provider is only just starting, and I consider it an honor and a privilege to be where I am now. I would exchange this experience for nothing. Semper Fi.