Back to Babylon: A Surgeon's Service in Iraq

by Richard J. Mullins, M.D.

Editor's Note: What follows are the personal observations of a surgeon on a tour of duty in Iraq . They relate to many aspects of life in the midst of the US Military occupation.

The History

Over four thousand years ago Babylon was a city on the Euphrates River , prosperous and influential. From their Babylonian thrones, kings ruled Mesopotamia, a region between the Tigris and Euphrates rivers, that with irrigation was converted from desert into productive farmland. Culture refined in Babylon contributed to the foundation of western civilization.

Babylonian architectural triumphs included the Tower of Babel , the Hanging Gardens of Babylon, Nebuchadnezzar's palace and the Ischtar gate. Hammurabi reigned over Babylon from 1792 to 1750 BCE and established a code of laws that were axioms (e.g. "an eye for an eye") that guided the orderly conduct of the city's society. Over the millenia control of Babylon has shifted constantly, and treasures have come and gone from the city. Today the Ischtar gate stands in a Berlin museum and Hammurabi's tablets are on display in Paris .

Nebuchadnezzar, who reigned from 605 to 561 BCE, established a reputation as the most successful Babylonian conqueror. He brought treasure and slaves to Babylon, including the vanquished citizens of Jerusalem. Historians have argued that the year he died Babylon reached its zenith.

That Nebuchadnezzar was peerless in Babylonian triumph was a historical judgement Saddam Hussein intended to change. Saddam built one of his many palaces in Iraq adjacent to the ruins of Babylon. He had a hill constructed and built a palace on it so he could gaze over the ruins of the ancient city.

Saddam ordered the walls of Nebuchadnezzar's palace reconstructed with "The City of Babylon was reconstructed during the era of the victorious Saddam Hussein, President of the Republic, protector of the great Iraq, the modernizer of its renaissance and builder of its civilization" imprinted on the bricks. Saddam gave the palace to his son, Uday, who corrupted the site with cruel debauchery until the end of April 2003 when the coalition forces defeated the Iraqi army. The Marine Expeditionary Force (MEF) occupied the palace grounds, and made it their headquarters.

The MEF was assigned responsibility for military rule of much of southern Iraq from Baghdad to Basra. Seven Marine battalions established camps in the major cities of Southern Iraq, and with platoon sized patrols walked the streets assisting local leaders to establish law and order. The Marines understood their mission had been transformed from combat to helping build a new Iraq and they were effective peacekeepers. Shiite Muslims in southern Iraq had suffered terribly under Saddam's rule. The commanders of the Marine battalions established a working relationship with the civic leaders and clerics. The summer of 2003 was dangerous, but no Marine died of combat wounds following May 1, 2003.

Activation and Arrival at Camp Babylon

I arrived at Camp Babylon in mid May 2003, after receiving my activation orders in mid March to join the 4th Medical Battalion which was forming up in Camp Pendleton, California. I am a reservist in the United States Navy. My billet, or assigned responsibility, is as a surgeon with the 4th Medical Battalion which is tasked to support the United States Marine Corps. (For over 225 years the Marine Corps has depended for medical care upon Navy personnel ranging from the corpsman assigned to platoons to surgeons working in field hospitals.) The initial war plan had the battalion setting up outside of Bagdad for the expected heavy casualities that would be the consequence of house to house fighting in the capital.

Being activated was not a surprise. In early March with the invasion of Iraq imminent, I had begun to wonder whether I would be called. As a trauma surgeon for the past 20 years, I had spent most of my civilian professional time engaged in activity that the military suddenly needed. Members of the medical reserves want to be given the opportunity to support our troops; if young American men and women engaged in combat are wounded, we are fully committed to providing their medical care. Following the large scale "down sizing" of the military over the past 10 years, medical assets within the military are stretched thin. Reservists are a critical component to fielding effective combat units.

For the first month following activation we were processed and prepared in Camp Pendleton, a large Marine Corp base north of San Diego. We were immunized against infectious diseases including anthrax and small pox. We trained with gear designed to protect us in the event of a biological or chemical weapon attack. I was issued a 9mm Baretta pistol and spent some time firing it on the weapons range. We watched CNN at night and followed the MEFs "march-up" from Kuwait to Baghdad.

In mid April we were flown to Kuwait International Airport and taken in buses with the curtains drawn to a large camp located in the desert, called Camp Okinawa. This was a barren patch of sand and dust, at least one square mile with a perimeter defined by an eight foot high berm. We sat in this dismal place for four weeks, and for me boredom converted to a restive impatience as we tried to obtain information as to where the 4th Medial Battalion fit in the plan.

In mid May, a small group of us were ordered into Iraq as replacements. We were flown in a C130 Hercules to a captured military air field at Al Kut. In heavily armed military supply convoys our group traveled through Mesopotamia and at various locations we were delivered to our duty stations. I arrived at Camp Babylon mid May, weeks after the combat phase had ended. Camp Babylon looked good to me after living in the hot dusty Kuwait desert where the only things one could see on the horizon were giant power transmission towers. Camp Babylon occupied 2000 acres, had date palm trees, and a wide irrigation river, a tributary to the Euphrates, defined the western boundary. I settled in with a small surgical unit.

Surgery at the Battlefield

I was assigned as a replacement surgeon in a Forward Resuscitation Surgical System (FRSS), which is a two tent, nine personnel, three-vehicle unit that was tasked to provide immediate support on the battlefield. During the combat phase, CNN had broadcast stories with vivid images on American television of FRSS teams performing surgery during MEF's combat operations. They were called the "Devil Docs," a play on the Marine's sobriquet Devil Dogs, FRSS units worked in harsh conditions and successfully accomplished life and limb saving surgery close to the battlefield. The FRSS was designated in after action reports by senior Marine officers as one of the innovative successes of Operation Iraqi Freedom.

I arrived as a replacement surgeon, a reservist who enabled the active duty Navy surgeons to return to their hospitals in the US. I spent the next 12 weeks at Camp Babylon, ready to provide surgical care should it be needed. In the time we were there, we performed four surgical procedures. While the lack of medical work for our group was excellent news for the Marines, it meant that we spent a long, hot, largely unpleasant summer accomplishing little that would seem to justify the time we spent away from our families and careers.

In Iraq during the summer of 2003, the Marine Battalions were seldom attacked. One reason given was that Marines have a reputation for being a very aggressive and effective combat force who respond vigorously if attacked. Another reason was that the Shiite civilian and religious leaders in the cities where Marine Battalions were located appreciated that the Marines were the reason that Saddam, and the Baath party thugs who persecuted them, had been ousted.

The FRSS was designed to be mobile, and consisted of two tents; one was the pre and post operative area, and one had our single operating table. In Babylon we had the bonus that a third tent was available for an officers barracks. An FRSS carried sufficient supplies to support 18 surgical procedures, but FRSS equipment was restricted to essentials-- a cumbersome x-ray machine is not included. The "system" was a surgical way station, and our goal was to achieve control of the life and limb threatening problems. Post-operatively we would immediately evacuate the patients usually to a bigger Army tent hospital on the outskirts of Baghdad called a Combat Surgical Hospital (CSH). At the end of the summer the CSH moved to Saddam's private hospital in Baghdad .

Behind our FRSS were several shacks and tents where a Marine Reconnaissance company was encamped. These Recon Marines patrolled the country roads and city streets in heavily armed Humvees looking for insurgents, particularly Saddam Hussein's Fedayeen militia, non-Iraqi fighters who came to Iraq for jihad and to kill Americans. The Marines removed the flimsy doors from their Humvees because the doors were an impediment if they suddenly needed to fire their weapons outboard. Furthermore, without a door they could quickly exit the vehicle in pursuit.

In mid summer our FRSS team operated on a Recon Marine injured when a grenade exploded in his Humvee. The wounded Marine was the driver, and he told us that as they slowed down approaching a town with civilians crowding the streets, adolescents began throwing stones at their vehicles. Distracted by the stones, he failed to see an assailant slip up from the vehicle's rear, and toss a small grenade onto the floorboards. He looked down, recognized it was a grenade, and made a split second decision: he put his foot over it. When the device exploded it injured only his foot. His fellow Marines formed a perimeter, while the corpsman cut off the Marines boot, and applied a compression dressing. When we examined him it was obvious a portion of his left foot was missing.

Our anesthesiologist, Captain Brad Aubuchon, put the patient to sleep with a general anesthetic. The other FRSS surgeon, Commander Rob Izenberg and I cleaned the dirt and debris driven into the wound, removed destroyed tissue, and bone, stopped the bleeding, and bandaged his foot. The other foot had several small puncture wounds from shrapnel. We did not perform definitive surgery, rather performed the first of what we knew would be several operations to achieve wound closure. Immediately after our procedure, the wounded Marine was evacuated by a Marine CH 46 Sea Knight helicopter to the CSH. The scowling members of his Recon unit made sure his stretcher was safely loaded on the helicopter, then they put on their helmets and flack jackets, inserted magazines in their weapons, and drove back to where the incident had occurred. I was told they planned to knock on doors with the intention of finding the individuals responsible.

Comments have been made in the medical literature that civilian surgeons, accustomed to elective surgery, would be stunned or overwhelmed if asked to treat horrific destructive wounds inflicted by military high velocity weapons. I doubt this is true. As a civilian trauma surgeon I have seen my share of mutilation and gore. Like most complex surgical problems, the approach to complex wounds needs be systematic; list the individual problems (e.g blood vessel disruption, bone fracture, muscle and skin wounds), and for each issue on the list apply the standard solutions. Perhaps the greatest skill of an experienced trauma surgeon in caring for the severely injured is a better concept of the optimal sequence. What is ironic is that many of the active duty military surgeons prior to this war in fact had very little experience managing major trauma victims. That is because only a few military hospitals function as trauma centers, and most operations performed in military hospitals are elective surgery. Thus when the USMC goes to war some of the most experienced surgeons available to care for the wounded Marines are Navy reservists called up from civilian practices.

From the Camp to the Community

In the three months I was at Camp Babylon, I rarely left the premises. Trips outside the gate were dangerous, and permission from the MEF command was required to travel. We were always escorted in convoys by Marines armed with machine guns. In July I was invited to visit one of the hospitals in Hillah, a city of approximately 50,000 people a few kilometers from Camp Babylon. A nurse with the rank of Captain in the US Army's Civil Affairs Brigade had been working with the hospitals in Hillah attempting to improve the flow of supplies out of the central warehouse in Baghdad. She had arranged for the Division Surgeon, Commander Miles Merwin to attend a luncheon, and he asked if I would like to go along.

Our Humvees were driven rapidly down roads outside the city, but then the drivers were forced to slow as we worked our way through crowded streets. It was 10 AM, and vendors in street stalls and small shops were engaged in a brisk commerce. Most men ignored us, but a few had cold stares that I concluded reflected either hostility or contempt. We sat in the vehicles facing outward, our weapons in condition 1, which means that a bullet has been advanced from the magazine into the chamber. It seemed prudent to give the impression of being vigilant, although with my background I knew I wasn't much of a threat.

At the hospital we had a cordial reception, and were escorted to a meeting room where approximately 100 physicians, mostly men, sat politely. Commander Merwin and I were led to the front of the room, and sat at a table on a low stage facing the assembled medical staff of the hospital. To my right was a short, young looking man, the regional Minister of Health. In a softly spoken voice he began the meeting by making a statement, first in Iraqi, and then repeated in English. He promised that his ministry would work to improve the flow of supplies from Baghdad. Then the moderator, who was translating, asked for questions. One of the first questions was who were the Marine Generals going to appoint as the chief of gynecology at the hospital. There were several questions about how we planned to protect the Iraqi citizens from the HIV virus that they thought the American military was bringing to Iraq. As the questions continued the Division surgeon and I realized that we had been brought there under the mistaken impression that since the Marines had defeated Saddam, the USMC would now rule in the same manner as Saddam.

Saddam's influence as a despot had reached into all aspects of life in Iraq. The medical education system in Iraq for much of the 20 th century was a flourishing enterprise modeled after the British system. Under Saddam medical and nursing education had deteriorated and become fragmented. A physician in Iraq would either have to cooperate with Saddam's Baath Party, or risk being ostracized or punished. The Commander and I spent much of the next hour emphatically declaring to the assembled staff that it was up to them to form an organization and decide how the hospital staff should be administered. At one point I became irritated when several in the audience criticized my failure to explain satisfactorily how I was going to solve the problem that medical supplies in Baghdad warehouses were not being delivered to the hospitals in Hillah. I told them I had come to Iraq as a Navy Reservist to treat the Marines and not as a conquering warrior. Furthermore I wanted them to know that I would have much preferred to have spent my summer gardening in Oregon. This experience of being sharply questioned highlighted for me how after eliminating Saddam, the two sides in this program to improve Iraq had some fundamental misunderstandings.

We were then invited to a tasty lunch, served by an attentive man and his children, although like most meals I had in Iraq, a cloud of flies hovered over the plate. The charming and gracious Minister of Health sat next to me, and explained that he was the son of a Shiite farmer, and had attended college and medical school in Ad Diwaniyah. Near the end of Saddam's failed invasion of Iran he had declined an invitation to join the Baath party and, and refused to serve in the army. Because of his un-cooperative behavior he was arrested. Showing little emotion he told me that he had spent nine years in a political prison in Baghdad, and had been released just prior to the war. He was appointed regional Minister of Health because the coalition forces could clearly establish his independence from the Baath party. I was astonished at his equanimity. I was struggling to tolerate a few weeks of boring life in Camp Babylon and was humbled that this man had endured years in one of Saddam's prisons. I asked the minister how he had survived, and he explained that the prisons had many educated men, and that through their families they had access to books, and taught one another. I wondered, but did not ask, how he had kept from being killed.

Another young doctor told a different story. Apparently many of the doctors would provide medical care in their homes; I gathered that if they could purchase a few supplies or medications, they could supplement their meager incomes. The doctor told me that one night a man came to his door with facial wounds. He brought the man in, treated him, and then the patient left. Later, Saddam's police, who had beaten the man before he had escaped, captured him, and the patient was compelled to reveal where he had been treated. Saddam's agent came to the doctors home, arrested him, and he was imprisoned for 9 months.

Trying to Get Home

The last week of August, our FRSS team was prepared to leave Camp Babylon and convoy to Kuwait with the Marine Battalion in Hillah, 1/4 (First Battalion, Fourth Regiment). An Army medical team had arrived and would take over providing emergency care to the coalition troops remaining at Babylon , most of whom were Polish. We drove our three vehicles to a factory in Hillah, where 1/4 had been encamped all summer, and formed up with their vehicles, excited to be leaving Iraq. All seven Marine battalions were scheduled to leave for Kuwait and flights home to Camp Pendleton. An hour before we moved-out, we were told there had been a sudden change in plans because a powerful truck bomb had exploded outside the Imam Ali Mosque in Najaf. The suicide bomber had killed over one hundred worshipers who were participating in Friday prayer services at this holy shrine. The explosion vaporized the Shiite leader Ayatollah Mohammed Baqer al-Hakim. The Ayatollah was a Shiite cleric who had been forced into exile by Saddam. Through the 1980s and 1990s he had lived in Iran and returned to his mosque to preach in May, 2003. He was considered a moderate and although critical of the US administration, he had urged pragmatic cooperation with the coalition forces.

It appeared that Saddam loyalists, using their characeristic brutal symbolism, had delivered through the carnage and damage to the mosque the message that if you cooperate with the American led coalition, you will be killed in public in a manner intended to humiliate. The August 29, 2003 explosion was a clear message sent throughout Iraq that Saddam still had power. Encamped throughout the summer in Najaf was 1/7 (First Battalion, Seventh Regiment), a legendary Marine Battalion whose discretion and sensitive support for local officials was considered a success. Perhaps this attack had been coordinated to make it appear the Marines were leaving just when Saddam was reasserting his control? The Marine Command immediately terminated 1/7's retrograde from Najaf, and our FRSS was ordered there to set up in case there was further trouble. The Marines stepped up their foot patrols in the city, disarmed a rival ayatollahs' militia, and made it clear they were not intimidated by Saddam's threats. Fortunately the violence did not escalate.

Within six days of the explosion, our FRSS was with the battalion in Najaf. They were encamped on a small campus of what was apparently an industrial studies college located near farms on the outskirts of Najaf. Compared to Babylon, it was small, dusty, and support facilities were austere. Each night packs of wild dogs would run through the camp. We had been told that rabies had been a problem in Iraq , particularly when the dogs got hungry and hunted in the cities. Sleeping in our cots, we would be awakened by growling, snapping and barking. The dogs seemed to be right outside the tent's wall. Walking out to the latrines in the dark of night was an adventure.

My tour ended when 1/7, the last Marine Battalion in country, pulled out from Iraq. In late September, there was a ceremony in Najaf; the Marine General turned command over to the Polish General, and we got in our vehicles and drove south. This time in Kuwait, we stayed in a large camp near Doha , that had lots of food, a view of the Persian Gulf and even a few amenities. After the desolation and poverty of Iraq, Kuwait, despite being a similar desert environment, had the look of a modern prosperous country, and I wondered if in 10 years Iraq would also look that way.

The Cost of Commitment

I was able to return easily to my civilian employment. But I am very fortunate. As a professor in the Department of Surgery at Oregon Health Sciences University, where my principal job is Chief of Trauma and Surgical Critical Care I do not have a large practice that depends upon established referral patterns from other medical colleagues. Thus I have not sustained the adverse impact on my career that many others have when they suddenly leave a business, profession or job that requires continuous nurturing. As an employee of OHSU, I don't own the office; I am not responsible for employee's salary and benefits. With a seamless transition, my colleagues cared for my patients when I suddenly left. In other words, a supportive employer and generous colleagues backed up my involvement to the US Navy reserves. Upon returning I have been warmly greeted and complemented by many colleagues, for which I am very thankful. Being mobilized separates one from family, and for many reservists that has been their greatest burden. Furthermore, being mobilized to active duty leads to a reduction in income that erodes the family's financial security. My wife Barbara was resourceful and through emails supportive of my morale. Our children are older adolescents and so did not experience the disruption that younger children might experience by the sudden perhaps incomprehensible departure of a parent.

At my age of 55, I found a tour of six months in Kuwait and Iraq stressful. I went from a suburbanite who enjoys sipping good wine while barbequing in the lush green backyard garden to a bored, sweating officer enduring unprecedented heat while scrounging through a box of MRE's (Meals Ready to Eat) to find the least unpalatable option. In summary, I think my father, God rest his soul, would be proud that I did my duty, as he had done 1941-1945; but like he said, there wasn't much pleasantly memorable about the experience.

I am among those Americans who believe we went to war in Iraq to oust Saddam Hussein, a brutal tyrant, and not to conquer the country and make it an economic vassal. Saddam was preparing his sons to perpetuate his visions that he was the modern heir to Nebuchadnezzar and could advance his agenda indifferent to any laws. On the other hand, I found it sobering that I was one of many combatants who over 4000 years have come to fight over Mesopotamia. The initial brilliant success of the US and coalition forces in the ground war in Iraq has been followed by months of escalating insurgency and an agonizing protraction in American deaths.

For the present, given the dangerous circumstances, it will fall to the military to play a major role in nation building. Freedom in Iraq, Afghanistan and the Balkans may ultimately depend more on whether the most powerful military in the world includes National Guard members and reservists, who are willing to leave their civilian professions, and bring their expertise to foreign lands to improve the quality of life. "Citizen soldiers" appear to be integral to a successful worldwide war on terrorism. The question is will our society continue to support a nation building agenda not just with its dollars but with its who citizens willing to do hard work in hostile environments. Currently in Iraq there are thousands of courageous military and civilian Americans making that effort. The next year's events should be a test of their resolve.