Fifi is going to come up, our keynote speaker this morning is Colonel Edward Horvath. It's a great honor and pleasure for me to introduce Colonel Edward P. Horvath, MD, PhD. Caring for America's young men and women in uniform is by far the most satisfying aspect of being in the U.S. Army Reserve Medical Corps, according to Dr. Edward Horvath, Chief of Professional Services at the 256th Combat Support Hospital in the Cleveland area. Dr. Horvath was commissioned in 1968 as an ensign in the U.S. Navy and served on active duty with the Medical Corps in the 1970s. Shortly thereafter, Dr. Horvath left military service and entered private practice, all while raising a family. Twenty-three years later, when his now-grown sons asked for his advice about what they should do with their lives, he reminded them of their obligation to serve their country. He then realized he had some unfinished business of his own. Several months later, Dr. Horvath found himself taking the oath of office for a second time in his life as he became a Lieutenant Colonel in the U.S. Army Reserve Medical Corps. Shortly thereafter, Dr. Horvath was mobilized to Fort Snelling, Minnesota, to serve as Deputy Command Surgeon. Later in the same year, he spent two weeks in Guatemala as part of an Army medical mission, served eight weeks in Egypt during Operation Bright Star, and was then assigned to a combat support hospital in Iraq. According to Dr. Horvath, being away from his wife was the single most difficult aspect of being deployed. He says, but now my wife and I have an even better relationship because of my military service and my children look up to me in a way they never have before. The experience of serving as a physician in the Army Medical Reserve Corps has changed Dr. Horvath on both personal and professional levels. Physicians share many common traits, one of which is a desire to serve. Otherwise, we wouldn't have gone into medicine, said Dr. Horvath, and we want to see interesting cases, new diseases, and unusual conditions. We want to have our medical knowledge and skill expanded, and we want to have new adventures. All these things are possible in the Army Reserve Medical Corps. Army physicians treat patients who generally need them, providing care for young people in uniform whose lives sometimes quite literally hang in the balance. He states, I can think of no finer thing to do in medicine than to provide that kind of care I feel privileged to serve. And on a personal note, I have heard Colonel Horvath speak and believe that he is one of the most inspiring lecturers to whom I have had the pleasure to listen, and I hope you too find this a great lecture. Thank you very much. Thank you very much for that kind introduction and for the invitation to speak to your group today. I've given some variation of this lecture about 60 times over the last six years. It's actually more of a presentation than a lecture to diverse groups, veterans groups, high school kids, community service groups. It's always a special honor to speak before my colleagues and a humbling experience. Before I begin this morning, I'd like to do the usual disclaimers. I'm not here to recruit anyone, so you can relax. I'm not here to justify the war in Iraq or any other war. There's no such thing as a good war, just sometimes necessary ones. I'm in uniform today and on duty, so I can't talk about politics, so please don't ask me who I'm going to vote for. And finally, my opinions expressed today are my own, not necessarily those of the Department of Defense, the Department of the Army, or my civilian employer, the Department of Veterans' Affairs. With all that out of the way, let's move on to good medicine in bad places. Basically, it's a story, an Army doctor's experience in Iraq three times, what I saw, how I felt, what I did about it, and in the end, maybe why I did it. Before I proceed, I wanted to show three young people I'm very proud of. This is my daughter, who is OBGYN in Minneapolis. She's in the audience today. She sent me this picture last week when I threatened to put a first grade picture in if she didn't send me one. And she also sent me this one to show me that she's a surgeon and I'm not. This is Lieutenant Andrew Horvath, a Navy pilot, flight commander of a Navy P-3 Orion. Andrew flew around my base in Iraq when I was there last year. He also flew missions over Afghanistan and over Libya, and unfortunately will be going back to the Middle East later this year. This is my older son, Ensign Damien Horvath, a Navy officer in public affairs, shown here interestingly in an Army uniform when he was in Afghanistan. I was in a theater with each of my boys at one time or another. Where you go where you don't know and never be the same. This is a line from a traditional Scottish hymn that I heard the first time I went out to Iraq. And it really describes in a very succinct way what it's like to be in a war zone. You go where you don't know. I didn't know anything about Iraq or its people. And I came back a different person. And everyone comes back different. Sometimes better. Sometimes worse. Just a little of each. Well, the Army never sends anyone off untrained. It had been a long time since I'd worn a uniform. So they said, Colonel Horvath, take your unit down to Guatemala and do a medical readiness training exercise or med ready. So we went off to Guatemala. And I always like to show pictures of the country for the geographically challenged, which includes me. I won't use the pointer because I just screwed up with it. Oh, there it is. That's too hard. Guatemala is a desperately poor country that suffered through a 30-year civil war that just ended in 1996. Over 200,000 people were killed, better term, murdered. It's still a very violent country. There are organized criminal gangs in the north and about 40 murders every week in Guatemala City. The Guatemalan people are wonderful people. They like Americans. They're one of our strongest allies. I thought I was going to be in a jungle up to my you-know-what in mud, but they actually sent us to the northern area in the mountains where little towns are tucked away without much in the way of medical care. They put us up in the barracks. And I know there's a couple of former military physicians here, so I don't have to tell you what this is like. For the rest of you, I bring you the pictures. I'm glad I can't bring you the smells. We went out and set up clinics in schools. This is a grade school in San Sebastian, and as you can see, these are all Mayan Indian children. Look at this schoolhouse. It was just an open courtyard and somebody put this metal roof on top. And when it rained, the kids knew where to put the pots to collect the rainwater. We were not universally welcome, although most of the people were happy to see us. Well, when you're in the military, you have to improvise. It's called a workaround. So we took classrooms and made them into clinics, waiting room chairs, a place to interview the patients, a place for the meds, and a filthy mattress in the barracks to substitute as an exam table. First day, I went outside, being a senior physician, kind of reconnoitered, and I stepped out and I saw this. And this line went around the entire town, and I thought that the whole third world had showed up. And I started to panic. We don't have enough doctors. We don't have enough supplies. And I said, pull yourself together. You're the senior guy here. When I walked back in, my physician colleagues asked, what's out there? And I said, nothing we can't handle, just a few patients. We have 6,600 patient contacts in 10 days. Well, you see the same things in third world countries that you see anywhere where there are human beings, heart disease, diabetes, arthritis, and the like, but you also see some unique things. And that's one of the reasons for this talk today, is to show you some of the conditions unique to the third world, also some of the types of combat injuries and non-combat conditions you see overseas. And finally, to tell you about the structure and function of the U.S. Army Combat Support Hospital. And this lady had cervical adenitis. We had no culture capabilities, so I don't know if this was TB, scrofula, or not. We sent her to a local hospital. This unfortunate gentleman had a significant nerve injury. He was a farmer and was harvesting his sugarcane, and he slipped with his machete and he severed his ulnar nerve. And he has the classic claw-hand deformity of an ulnar nerve paralysis, and as you can also see, marked interosseous atrophy. Unfortunately, this hand is useful only as a claw, it doesn't have any other function now. This is a different type of paralysis, Saturday night paralysis, radial nerve palsy. This gentleman got drunk and fell asleep over his forearm, this will come back. There was a lot of Bell's palsy in the third world, and I never looked at any data, so I can't tell you if it was all that much more prevalent or I was just imagining it. This lady, she couldn't wrinkle her forehead, so it's peripheral, which is the usual case. And most of these go away, as you know. You have to protect the eyes, you can see here she couldn't close her eye. Everything gets infected. A young girl with an insect bite going into a cellulitis. She had no culture capabilities in most places, and treated everything as if it were MRSA, even if it wasn't. There's a great picture from each of these, and this was the picture of the trip here. This lady brought these kids in, and it had been like 30 years since I'd done pediatrics, but I was there. So two hours later, I had examined it all, they got suckers, and I got a great picture. Well that was good. Good job, Colonel Horvath. Now we're going to send you to the desert for Operation Bright Star in Egypt, and this was a biannual exercise every two years held in the Egyptian desert at the El Alamein battlefield from World War II. Obviously with the current political situation in Egypt, it's unlikely you'll ever be held there again. This went on for quite some time. Our combat support hospital provided care for the Americans there. There were 32,000 troops from 14 different countries, land, sea, and naval air forces in this exercise. This was my favorite picture from this particular deployment. It's not perched on there. It was just a coincidental shot of a Navy medevac helicopter by the pyramids. That's as close as I got to the pyramids. This is Egypt. Very much in the news these days. You can see where Cairo is there in the center. The seaport of Alexandria. And right below Alexandria, which is not labeled, is the El Alamein battlefield from World War II. We were advised not to pick up anything that we hadn't dropped ourselves, because tourists have gone there, picked up pieces of equipment, grenades, that were revealed by the shifting sands, took them home, and showing them to their families, pulled a pin. They were live munitions. This was not a combat zone when I was there, but the terrorists did show up down at the tip of the Sinai, and the resort city of Sharm el-Sheikh, they blew up a hotel and killed 126 people. And nearby, in the Gulf of Aqaba, rocketed Navy ships that were there. So it was a dangerous area even then. Because this was a battlefield at one time, and a place for military maneuvers, there were a few paved roads, surprisingly. Living conditions, which are always fascinating to me. This is not exactly a five-star place, but it was much better than where the enlisted personnel were sent. There's no privacy. Anyone who's been in the military knows it's one of the first things you lose. I thought this was an interesting juxtaposition of a shower next to the toilet and no shower curtain at all. They took me out and said, Colonel Horvath, put your hospital here. And I said, there's nothing to put up. Where is it? Well, it did show up in these big boxes called connexes. This huge piece of equipment places the hospital supplies where you tell it. And hopefully, you've laid out the hospital properly. Because if that's the ER, and he puts it there, and the ER's over here after he leaves, you're in big trouble. Well, we started to set the tents up and found out there was bedrock about three inches below the sand. And we wound up pounding metal stakes day and night. The hospital gradually came up. You put the Red Cross flag on, and there it is, the US Combat Support Hospital, the basic medical unit that the military uses in a war zone. You can see the entry point there, which is the ER right there. The ambulances would go out, pick up casualties from the landing zone. You'd go into the ER. If they needed surgery, they'd go back. I still can't work this thing. There's the operatory right there. It's a hardwall structure. Actually very nice. X-ray was located here. We had pharmacy lab and X-ray. And the patient beds are back in this area. One of the major functions of a combat support hospital, one of my major concerns all of last year in Iraq, was to maintain an adequate blood supply of blood components, back red cells, platelets, and fresh frozen plasma. And these have limited shelf life, as you know, and it's always difficult to get these in a deployed environment. The combat support hospital saves life, limb, and eyesight. We don't do plastic surgery. We don't deliver babies, sorry, at least not unless we have to. We do resuscitative surgery. Grievously injured people come in. We save them. And if they need to be sent on for more definitive care, they go to Landstuhl in Germany and then back to the States. If you arrive at a combat support hospital and you are not already dead or in the active, irreversible process of dying, the chances are 97 percent that you will survive and go on to other care. The flip side of that is we now have very severely disabled young people who would have died in prior wars. And I've seen them in wounded warrior areas and hospitals, and their courage puts every one of us to shame. Why does it work? It works because of this, the medevac, a U-860 Black Hawk converted into a flying ambulance. The brave men and women who fly these will go anywhere, in any firefight, in any weather to pick up our soldiers and bring them to a combat support hospital. They're really just absolutely incredible. At the peak of the Iraq conflict, there were five combat support hospitals strategically positioned over the country. No American soldier was more than a half hour from resuscitative surgery. And during this training exercise, we had some pretty severe injuries. We actually lost a person. And you do have deaths during training exercises. People are jumping out of planes using live ammo, and there were 32,000 of them. This officer decided to want to commune with nature one night and tripped over barbed wire and broke his ankle. I had to go fetch him. I was glad I didn't run into a cobra at the time. Marines do funny things. I'm sorry if there are any Marines in here. I apologize in advance. This young man thought he could jump over a concertina wire. He didn't make it. And here's the inside of one of the surgical operatories. I'll give you a better view later. This was an interesting picture. It illustrates a number of things. First of all, the bi-generational nature of the Army. The young man there was 18. He just graduated from high school a few months earlier. The old guy was 40 years older than him at the time. And he developed one of the two epidemic diseases that tend to go through military groups. He had tracheobronchitis. It was very severe. Everyone got it, including me. The other condition you see frequently is gastroenteritis, dysentery. Usually it's enterotoxigenic E. coli. If you have culture capability, you'll find that out. Once in a while, you see a salmonella shigella, a campylobacter. And those that you can't determine what they are, they're probably viruses. Unless the person has some indication of a severe gastroenteritis, bloody stools, severe abdominal pain, high fever, you get one gram of azithromycin, a handful of low-modal, two liters of IV fluids, and out you go. Unfriendly wildlife. I'll come back to some of the creatures that crawl around there in a moment. But this was a spider bite. You can see the central punctum. The spider venom causes tissue necrosis, and this had to be IND. Everything gets infected, started out as a blister, became a cellulitis that went up his leg, required intravenous vancomycin. Does anyone know what this is? You don't see this very often. This is a smallpox vaccination, and the scab being formed, and it's very intensely itchy. And so this young man, in order to avoid scratching it off, put two Band-Aids on there, and found out that he was also allergic to the Band-Aids. So he was in bad shape. Another itchy, rash young gal comes in, and she said, well, I've got this. I don't know what it is. What can I do about it? I looked at her and said, you know, if I didn't know any better, I'd say it was poison ivy, but there's no poison ivy here in the desert. And she gave me a wry smile, and she said, I had it when I came. It was poison ivy. Well, I demonstrated that I could run a hospital, sort of, in the desert, and it was time to go to Iraq, and I won't put all these dates down. It totals up to about 20 months altogether during Operation Iraqi Freedom, and last year, Operation New Dawn. Last year was pretty much the entire year, and one of the physicians that was at the brigade level in Baghdad is here today, so he'll correct me if I make any mistakes. You don't see this much in the news anymore, Iraq, and you see it's in one of the worst places in the world, bordered by Syria, Iran, Turkey, Saudi Arabia. Most of the troops, all the troops that go there land in Kuwait, and then they're distributed throughout the country, usually in Baghdad. North of Baghdad is Tikrit, Saddam Hussein's hometown. I'm not giving up on this, but you can see it on the map. Over the course of my time there, I was in Mosul up north, which is the site of the ancient city of Nineveh, in the western desert, Al-Assad, and then down near the Persian Gulf at a prison hospital there. Thousands of miles of travel, and during my first time there, well over 1,000 miles of convoys. And the roads in Iraq are very dangerous, and this was the favorite picture of the trip. It was outside of Baghdad in March of 2006. There was a civil war going on at the time. Hundreds of Iraqis were dying every month. Shia and Sunnis were killing each other because Al-Qaeda bombed the Golden Dome Mosque at Samarra to set off the sectarian strife. The gunfire had stopped for a while, and I handed my camera to a young enlistee, I said, I took a picture for my wife. And he took this picture. And I think it's interesting for the expression on my face, which is fairly blank. I showed this to young people, and the boys wanted to know, of course, they see the 9mm, which I carried everywhere. Did you kill anyone? And my response is, I'm a doctor, I don't kill people on purpose. Sorry, bad joke. One lady asked me why my blood type was stitched on the outside of my body armor, and I felt like asking her, what do you think? Four days after Christmas in 2005, I was on my way to Abu Ghraib Prison Hospital. I don't know what I said to somebody to get sent there. The freeway system there was fairly good, as you can see. Unfortunately, bad guys would go over the overpasses and drop things in on you. This was very disturbing, and it bothers me even to this day. Iraqi children came out to beg for food and water, and I didn't anticipate seeing this. We moved on, and you remember the movie The Wizard of Oz, and Dorothy, the Tin Man, the Scarecrow, and Cowardly Lion come up to the sign, Wicked Witch Castle straight ahead, I'd turn back if I were you. This is the Iraqi equivalent of, I'd turn back if I were you. You can go to Fallujah and get killed, go to Baghdad and get killed, or go to Abu Ghraib and get killed. We continued on and pulled into this Byzantine prison fortress called Abu Ghraib, which had already become infamous because of what a group of Americans did there in 2004. I'm not defending that, but you have to remember that Saddam Hussein murdered 10,000 to 20,000 largely innocent men, women, and children here, usually after torture. Their bones were sticking up in various places on the grounds. We just picked them up and brought them in. I didn't have a set place to stay, and they said, would you stay here? I said, you know, I don't really like used tire showrooms as bedrooms. And in my time back and forth to Abu Ghraib, finally they got annoyed and said, we're putting you in here. And I had never been in jail when I was in high school or college, so this was a new experience to me. As you can see, this is pretty stark. I don't know who put the butterfly up, but somebody on the lower right-hand corner was kind enough to leave me a bottle of his urine. And there are no flush toilets, and so if you're a guy my age and you have to get up and visit the urinal at night, you take a bottle in with you. And for obvious reasons, Gatorade bottles work best. And you learn rather quickly never to pick up a bottle of yellow Gatorade. Although I think the electric light composition is about the same. This is the guy who built Abu Ghraib and murdered the people. This is a big mural right inside the prison fortress. Our hospital was pitched in the distance. You can see a building there. And we pitched it inside to get some protection against mortars. We actually just put the tents up inside this building. This is a collage of pictures of what the hospital looked like. In the lower left are insurgent patients that we took care of. Upper right is the ICU, and the right side is the emergency treatment area. As you can see, it's pretty primitive. We took care of 5,000 detainees there under conditions that were fairly stark for all of us. And that was our main function. But we also served as an overflow in case there were mass casualty events. And this day, January 5, 2006, was one of the worst days in the war up to that point in time. There were coordinated attacks across the countryside, including right outside the base. Over 100 Iraqis were killed that day and 11 Americans. So we got the overflow. This was my first mass casualty. It would not be my last. And I will never forget the sounds and the sights of that day. And I took one picture to show. And it's what happens when someone drives a vehicle-borne explosive device, a V-BID, into your Humvee, and it's packed with ball bearings. As you can see the damage done, four soldiers were injured. We saved everyone that day. No one lost their life, a limb, or eyesight. We won that day. We would not always be so fortunate. So they decided to send me down south to be the medical director of the prison hospital at Camp Bucca. And Camp Bucca was a very large facility at the time with 12,000 detainees. And of course, they didn't like being there. So there were riots. They burned the place down periodically, always trying to tunnel out. Some of these were incredible. The hospital there down in the lower right corner was a very nice facility. As you can see up above that, the operating room looks very much like an operating room in a small hospital in the U.S. Excellent supplies, dentistry, and they got better care there than they would have in their hometowns. They told me it was relatively safe in the South, but the day I arrived, this happened right outside the gate. Two young soldiers were killed. The one on the left was a teenager. The one on the right was 24. He was scheduled to go home in two months to be married. So the stark reality of the war intrudes in your life. You see different things in theater that seem more common than they are back home. I've already mentioned bell palsy and the third world. Everyone got hives, and I don't know why. Probably different antigens. We were always treating widespread urticaria. Everything got infected. And sometimes we got so busy, they'd take an internist and put him in the operating room. The surgeon on the right said, Edward, would you come and give me a hand? I said, I haven't done surgery for 34 years. And he said, well, you should do it every 34 years to keep up your skills. Two procedures later, I realized why I'm not a surgeon. But for my daughter, see, Dad can do surgery. TB was extraordinarily common in Iraq. This young man was an American contractor for a British firm. He came in with pleural effusions. He had pleural effusion TB, primary TB. He did well. I initially thought that all the TB there would be multidrug resistant and actually was all sensitive to INH and rifampin. This is a close-up of a lesion that's about five centimeters across on a forearm of a young man. Does anyone know what this is? It's cutaneous leishmaniasis. It's a parasitic disease spread by the bite of the sandfly. It usually goes away on its own. If it's really bad, we would send the soldiers to Walter Reed for treatment. But we used an interesting form of amphotericin. It's liposomal amphotericin B, which is far less nephrotoxic than what we used as house officers. And after about 30 days, it was really quite much better. This is a cross-section of a surgical specimen, right lower quadrant terminal ilium of a young insurgent. The surgeon thought it was an appendiceal carcinoma, and obviously we're not a chemotherapeutic center, so this person's outcome looked pretty grim. We sent the specimen to Baghdad. Nonetheless, we had a pathologist. He called up excitedly. He said, sir, these are sulfur granules. This is actinomycosis. So this young man went from having a terminal malignancy to a treatable infection. Suicide is a big problem in the Army, anyone who reads the news. So far this year, one soldier on average per day has taken his own life or her life. This was an unusual suicide attempt. This young man took an overdose. This is his lower extremity. He took SSRI and developed serotonin syndrome, rapid myelosis, massive swelling of his muscles, compartment syndrome. He had no pulses in his feet. So he had to be rushed off to surgery and have a fasciotomy performed, the first time I'd ever seen this done in a circumstance other than penetrating trauma. And as I wheeled him into the operating room, I looked at him, and he was the picture of depression, and I said, son, don't worry. You'll be okay. He said, sir, you can't stop me from killing myself if I want to. He was sadly correct. On this last deployment, one of our officers shot himself right in front of us. We fly around Iraq a lot, usually in Blackhawks, usually in pairs for obvious reasons. If one goes down, there's another there to protect you until help arrives. You see remarkable things. Everybody thinks Iraq's a desert. It's really not. There's tremendous averted areas. This is the Tigris River near Mosul, the site of the ancient city of Nineveh. It was not unusual for me to fly back and forth from the Euphrates in the west to the Tigris in the east, across Mesopotamia, and it was very lush. This is a small town with crops growing. The Iraqis are very good at irrigation. We stopped at the oasis of Abraham in the western desert, and this is a beautiful little body of water, a beautiful pine grove. The legend is, of course, that Abraham watered his flocks there 4,000 years ago, and for all I know, he did. One of the officers said, sir, let's take a little walk through the pine forest, and I thought this is not a good idea. And we stumble on a MiG-15 that was just sitting out there, and there was a couple of other Russian jets just right out in the open, and it turns out that Saddam Hussein had buried his high-performance fighters at the beginning of the war, hoping the Americans would leave and he could bring them out again, well, obviously he became unemployed shortly thereafter, and these things are just sitting out there. These are ruins of a Christian monastery from the 4th century, pre-Islamic time, right outside of Mosul. It remained a functioning monastery until the 17th century. During the war, it became the site of a big tank battle between the Iraqi and American forces, and the Iraqis finished second, and all their wrecked equipment was parked across the dirt road. So you had this striking contrast of a religious symbol and symbols of war, both in ruins. No trip to Baghdad is complete without visiting Saddam Hussein's place, the Al-Faw palace. I think it was a billion dollars it took to build this. I can't do justice to the four-story rotundra. I did the best I could. Magnificent marble hallways, it was just a palace in the finest sense of the word, including a throne. How many times do you get to sit in a dictator's throne? That was Saddam Hussein's throne. The workmanship was terrible. Look at this. You and I could do better than this. Saddam was very unhappy with this palace, and he terminated his business relationship with the architect in the only way he knew how. He had him executed. He was in a generous mood that day, though, and spared his family. The Americans thought he was there during the onset of the war and tried to cut his retreat. He wasn't there, as we all found out later. During my time in Baghdad, I spent a few weeks at this little summer home in the middle of Uday's Lake. Uday was Saddam's sadistic son, and he'd bring his friends for parties in which they would rape and kill people. And I stayed in this one and walked out one day across this walkway, and the fish were following me. And when I got inside, I said, what's with the fish? And he said, sir, they're wondering why you're in such a big piece. I said, OK, what's the rest of the story? Uday would take anybody he didn't like and put them in a plastic shredder and collect their body parts and feed them to the fish. And I thought, this could not be true. No one is that sick. It was true. Back to the children, I came across this quote when I was there, to him we cannot answer tomorrow. His name is today. And the plight of the Iraqi children came back to me at Camp Bukha, where families would drive down to Camp Bukha from Baghdad, a dangerous journey in itself, to visit the children, their detainee fathers. And they were allowed five minutes of a contact visit to hug. And then they could stay longer, but they'd have to go behind a chandeling fence. And I watched one of the most distressing scenes of young Air Force MPs tearing children away from the arms of their fathers. They were screaming and crying. And the Air Force MPs were crying as well. And then I watched them leave, and their eyes were burning with hatred for us. And I could understand why. And I asked the chaplain, what can we do to make them hate us less? And he said, well, I don't have very much of anything to give them. So I went back to the generous people of northern Ohio, scout troops, schools, churches, and we filled a warehouse with clothing, supplies, educational materials. And when the children left, we took them and their mothers aside, gave them two shopping bags, and said, here, take anything you want. I was impressed by this young man. He was a delightful person, a very kind face. And I'd like to believe that if he survived the war, that he might be a physician someday. Children being children, able to forget about the war for one day. Well, I went back because the images of the children haunted me. And I was sent to Camp Spiker in Tikrit, north of Baghdad, and stuck in this. And contrary to what you might think, the palm tree is not Palm Springs. I was put in a latrine that had been converted into a room. They just cut the pipes off, and it was filled with black mold. And that's where I spent three months. I didn't have the worst place, though. This is one of the surgeons from the Cleveland Clinic. He got this fishing shack. The hospital structure there was a little different. You could see there was hardwalled buildings in the center, where the emergency treatment area was, and the ICU. We configured it to take advantage of every hardwalled structure we had as a matter of safety and security. The place was wrecked. I mean, it had been hit hard at the beginning of the war. This is a national soccer stadium. As you can see, the tremendous damage it sustained. Things were dangerous. We didn't go out on the roads if we could avoid it. But the war came to us. This is a mortar. It hit something. It was burning. It was a big base. It happened all the time. After a while, you didn't even pay any attention. Inclement weather. This is a dust devil. Not as bad as a tornado from Kansas, but not pleasant. This is the real color. Not doctored. Not Photoshopped. This was a sandstorm that just kicked up in the middle of the day with this apocalyptic yellow glow. Sometimes these would last for two, three, four days. And the only good thing about it was the war would stop. Nobody could see each other. They'd kill each other. So it got quiet, but unfortunately, the sandstorm would end and the killing would begin again. You all know about the weather there. Anyone who's been there, this is actually not such a bad day. It gets a lot hotter. Here's more unfriendly wildlife. This is a death stalker scorpion. You can guess how it got its name. She had polyvalent scorpion and snake antivenom. For some reason, it didn't cover this particular scorpion. These are spiders. Don't worry, they're harmless. Does anyone see what this is? Someone said a snake. Yes, it's down there camouflaged. She crawled in an electric box in January because it was warmer there, and the electrician didn't see it for about a half hour until his buddy came up and said, don't move. This is a Mediterranean viper. It was cold and it was dormant, otherwise he would have been bitten. You have to improvise, do workarounds. This is a rather unique entryway to an OR. We made our own wheelchairs. They work really well, by the way. We had to configure our own latrines. We didn't have very good facilities, and so we had to have a unisex latrine. It was the only one there. It's not like in this country where the boy goes in, does his business, comes out, the girl goes in. In this one, it was a true unisex latrine. You went in together, and it was just like being married except the woman in the stall next to you was not your wife. This is my funniest potty humor. The Americans came there and brought toilets, and in that part of the world, as in many other parts, people squat over holes. So the Iraqis would see these, and they'd stand on them. After some nasty falls, we had to instruct them that you're much happier if you sit down on this thing. This is a group of physicians for the 325th Combat Support Hospital in Iraq. We had two general surgeons, OBGYN. We had several that came with us at various times, anesthesiologist, two internists, a couple of ER docs, and four CRNAs, and that was the team there. I was an internist, and they put me in the ER, which was okay, and I was bright-eyed and bushy-tailed my first day, and after two weeks, I wasn't so happy. And it was because we had MassCal after MassCal after MassCal. This was the area of the last ongoing combat operations against Al Qaeda, and the fighting was very intense, and we got patients in large numbers, not infrequently. And every MassCal is a panic for the first 10 to 15 minutes, and it may be for longer than that. This is a shrapnel injury. You have to go in and fish out all these metal pieces and irrigate the holes. A lot of burns. This was a 50 percent third-degree burn in an Iraqi soldier. There are no burn centers in Iraq. All we could do is give this man comfort care. It was very sad to see these people die. We did some skin grafting when we could, when we had time. A young soldier who got hit by an IED that was in a rock pile. As you can see, he wound up with part of the rocks in his jaw. But he was very lucky. Look at the one next to his cervical spine and carotid artery. Another near miss near the cervical spine. This was an IED with ball bearings. We obviously didn't go fishing around for that. This is a different type of injury. This is a dog. This is a military working dog, Duke. And Duke jumped on an insurgent who snuck behind our troops before he could throw the grenade. It went off. The insurgent got the worst of it, but Duke took some shrapnel. And we're proud to say he survived. We care for the military working dogs as we do our patients. They go on the same carts. They go on the CAT scan, whatever we need to do to save their lives. You could be driving around on a Sunday afternoon with your family and wind up with a piece of a car in your head if you run over an IED. This was a traumatic brain injury up in the top there. You can see intracerebral bleed. He came in clinically with a pretty severe concussion. When we saw this, he got sent out. Unfortunate young girl, 10 years old. You can see the right eye. She took a piece of shrapnel in the eye. It's got air in it. I thought she would lose the eye. We sent her to the ophthalmologist in Balad, and he saved this eye, actually. Bullets wind up in strange places. This one's in the marrow cavity. We knew better than to go fishing around for that, so we just pinned over it. They came out with this picture during a mass call and said, sir, what should we do? And I said, well, it doesn't look so horribly bad. Why don't we call the orthopedic surgeon? And they said, sir, you better look at this. So I went over and took a look at it and decided this was going to be an amputation, and that's what it turned out to be. Young shepherd boy. When was the last time a shepherd came into your office? He was out there, 14 years old, picked up a .50 caliber round, a live one, and what does a teenage boy do? Taps on it, right? It exploded. It severely damaged his hand. Our talented orthopedic surgeon was able to put it back together. This young man was a very fortunate young Iraqi soldier. As you can see, left side of his hip, there's a hole and metal fragments from a low-velocity round. The bullet wound up in his scrotum, which made it very easy to retrieve. This is a very sad case, a CT of a pelvis. Multiple fractures. A very vascular organ, as you know. We missed this on the plane film during a mass call. We didn't see it. It was a lousy film. The individual looked like he was okay and then went into shock. He got this CT. He died. We missed this one. You feel badly about it for a long time, but you can't save everyone. Other common things you can see up there, an inflamed appendix. Why it was common there, I don't know. This is no surprise, renal calculi. We saw several of these every week. One Saturday morning, three of the first four patients I admitted were kidney stones. Two men. The children were very disturbing. Two-thirds of the casualties in any war are innocent men, women, and children. This young girl was three years old, and she had the misfortune of being near a suicide bomber, and she had her leg shattered. I thought she would lose them, but a very good neurosurgeon fixed them. She was not the worst I saw, however. One day during a 29-person mass cal, they wheeled someone in, sir, take this one. A young Iraqi girl. She was obviously in shock. Her blanket was covered with blood. The routine is you tear the blanket off the clothes, find the holes, plug them, get them out of shock, keep them alive long enough for the surgeons to do their work. When I ripped the blanket off her, I saw something that I'd never seen before and I never want to see again. Her left leg was severed and the groin was laying on the table. She was in shock. We managed to save her, and a very talented orthopedic surgeon on the right did the repair. As you can see, she's a beautiful young girl with one leg. Well, you see these things and you want to hate. You're very angry. Before I went to Iraq, the first time I saw this quote from the New Testament on a blackboard. You have learned how it was said, you must love your neighbor and hate your enemy, but I say, do you love your enemies? Very difficult thing to do, especially when your enemy happens to be this guy, Abu Musa al-Zarqawi, the head of Al-Qaeda in Iraq. He personally beheaded Nicholas Berg on the videotape that many of you saw. His minions would go out and behead children in front of their parents as an act of intimidation. A true psychopath. He wound up at the wrong end of a projectile fired by an F-15, and I'm glad he's gone. But is this the enemy? We had 242 juveniles at Abu Ghraib, 13 to 17. They would come in paralyzed, half-dead, screaming, crying, without anyone in the world because someone gave them an AK-47 and said, here, go out and shoot the Americans. They didn't know any better. I had, during a mass casualty event, there was a young man laying hooded and zip-tied, and I was working another patient with the Iraqi interpreter. And this young man and the Arab interpreter, Iraqi interpreter, were chattering back and forth. I said, who is that? And he said, no, he's Al-Qaeda. I said, really, what's he saying? He said, well, he knows I'm an Arab. He has no quarrel with me. He wants to kill you. So I wanted to go over and rip his hood off and tell him how much I hated him, but I didn't. He left, and three days later, he came back. He had been tortured. His hood was bloody. I rolled him over. He had been whipped. I turned to the MPs and said, I need his story. It better be good. He said, sir, we have to turn these people over to the Iraqi police. They hate these guys. They were torturing them to death. We found out about it and went to save him. So the irony of our soldiers saving our enemies from our allies struck me as well ironic. And I turned to him, still hooded, and I said, I'm an American Army doctor. I will care for you. What did they do? And the response they kicked in my face. So it was time to take his hood off. Our interpreter put his hood on, of course. I'm peeling off his hood, and now I get to see Osama bin Laden Jr. I get to see an Arab Adolf Hitler. I get to see someone with horns. I get to hate. He was a kid, a teenager. He looked up at me with his boy eyes and smiled. I can't hate you. You're someone's child. So I cared for him, and at the end, I put my hand on his forehead, as I did frequently there. And I said, I'm an American Army doctor. I'll take care of you. He began to cry and took my hand and rubbed it in his tears. And so you leave there with more questions than answers. As Mother Teresa said during the war in Lebanon, what do they feel when they do this? I don't understand it. They are all children of God. Why do they do it? Indeed, why? Well many people ask me why. Why did you go? You were an old guy. You should have been planning for your retirement, not going off to war. My first time there, I was with a number of physicians, and there was a bimodal age distribution. Young people in their 30s who were there serving an obligation that had occurred from financial support during residency. And there were a bunch of guys in their 50s and early 60s. And I took each one of them aside and asked them why. And they all gave me a variant of the same answer. It was very simple. I came to take care of the kids that grew up with mine. Their children were grown, oftentimes in medicine or the military, and I felt an obligation to care for young people. They were there to take care of the neighbors' kids. This is Chris Frazier. He looks like he's 15, but actually at the time he was 20. Our paths crossed at Tikrit one fateful day. Chris was in an airborne assault at night. He thought he was at 5 feet. He was at 35 feet when he jumped out of the helicopter. He remembers nothing. They told me that he had fractured his wrist and his ribs when I took report the next morning. He was okay. I started to go through the CT scans. I came to his. His spleen was ruptured. It had been missed. So I raced into the hospital tent. He was in the back. No one was paying any attention to him. We had a lot of sick patients. And I walked up, and he was in shock. So I grabbed the medics. We started IVs. I called the surgeon. I wheeled him into the operating room, and to settle him down, I talked with him a little bit. Where are you from, Chris? Lakewood, Ohio, sir. Well, Lakewood, Ohio is about six miles from my home in Bay Village. Interesting coincidence. Chris went in. They took out his pulverized spleen. He had a tough postoperative course but survived. And I never thought I would see him again. Several weeks later, I was home and got called back to active duty. For the second time that year, I was at the airport in a uniform being sent away. I walked up to the airline desk, and there was a woman there in her 40s, and she said, are you coming back from Iraq? And I said, well, I was there. I have to go on active duty again. Well, my son was there, she said. Really? What happened? We got wounded. He fell off a helicopter. I said, where? And she said, at the 325th Combat Hospital near Tikrit. She said, you know, they thought he wasn't very seriously injured, but that morning a doctor came in and took him. He knew what was going wrong, and he took him into the operating room, and he saved his life. I thought, oh, my goodness. How could this be? How could this coincidence occur? She had not identified herself, and she didn't have a name tag on, and I said, Mrs. Frazier, how is Chris doing? She looked at me with an astonishment. It was you, she asked. And I said, I took care of your son that morning. How is he doing? She began to weep and embrace me. You saved my son's life. My little boy came home to me because of you. I was, I didn't know what to say, but in that moment, that one moment, it all became worthwhile. The hardship, the separation, the danger, all became worthwhile. Chris and I see each other a couple times a year. We get together at least once for dinner to celebrate the fact we're both still alive. Chris was married this past August. He's doing fine. So to end this talk, I'd like to show you the faces of our young people in Iraq. Some of these young people did not survive. They are the neighbor's kids, they're the reason that I went and many of the doctors went to Iraq. They're the reason that I went and many of the doctors went to Iraq. They're the reason that I went and many of the doctors went to Iraq. Thank you for inviting me here.

Colonel Edward Horvath

U.S. Army Reserve Medical Corps

physician

Iraq

medical missions

combat support hospitals

tuberculosis

injured children

compassion